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q'an Joaquin County <br />Y <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />ORIGINAL <br />RE49� 10% N <br />Nov o MbTa Iv <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br />PERMIT/SEgI g <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made 1 ce with San <br />Joaquin County Development Title, Chapter 9-1115.3 <br />aandd the Standards of Sap Joaquin County Environmental Health Department. p <br />WELL Location f 3o N, �Ln+eX St Cross Street h n S - City rk46r, Zip 15«v4ascel# rs -! 12 00 2, <br />POwne ERT i+ ^ t � �n ddress 305 N • e lda�o aCity (.4+M. Zip 15 (090ho <br />Pne# 2 0 _ r V T <br />It <br />C-57 Contractor Ry=- `w' A Address C City�(�jar zip � 1(;ic#�h Phone# 53L 66�'zYZ7 <br />Consultant/ Sub Cntr�YrnarfUJla) 7iDun AddressCity tr a Lic# (% b Phone# / t s — s / 0010 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING '_,'P &EOF:PRQ�PHYQROP F�, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />]OIL BORING # 0 OVER -BORE. DIAMETER <br />WELL # G Q'RESSURE GROUT <br />0 'Other V ► - 1 GROUT SPECIFICATIONS J� <br />COMMENTS: C <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: - <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE <br />YP i OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL CO TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />*SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS n <br />0 OTHER: � <br />0 OTHER APPROX. BORING DEPTH i 6 �L 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: n <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. - <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordina es, ule and a uI tions, and all applicable California State Laws. <br />Signed xw�� Title/Company IrPac��eu �0«0 Zr1C_. <br />Print Name Q!/ ( Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 13 G N o r+I H t)n+P,,r S -tree+ <br />WORK PLAN DATED: N o Ve-m b ,a r �% 2004 <br />Application Accepted By Date Issued 6 2 Area 145? <br />V <br />Grout Inspection By ir�(jr;A Mde!4rhyfy Date 11-1 �b Final Inspection By i2 Aate /t1—/Z. —01� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: A d UJ oin ; rL <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P EQ T # <br />INVOICE <br />35r I <br />99.c0 <br />89.0 <br />SR# 0040300 <br />C-57 WC WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />I:n D -19 -01 -nu I <br />