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San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />Ind E _-- <br />SIT'E <br />IT C,,�4TION <br />� <br />JUL °'�TIV <br />ENVIRONMENT 444H <br />PERMIT,ISERVICES <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 3(S 74 St1tGET Cross Street E',vST ST City %RACY Zip 95374 Parcel# 233 - 3 70 - oI, <br />PROPERTY 770'40' ✓��T <br />Owner6w/F/.9O Sfl4eooc 0/f % Address /4175 W. [DWBL L City T?AC Y Zip S�_Phone# <br />C9 S 97u <br />C-57 Contractor 4'CA Address 30!/ 7>,e. City /�jTu t Zip 9 DU; Lic# Phone# Q3/ -LG 2 •¢/7dr <br />Consultant / Sub Cntr ce.4 Address 20Z Y.tV. Phone#201- 1frS-CrIa <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />Y <br />Township <br />(CPT, EOPROBE, HYDROPUNCH HAND -AUGER, OTHER*) <br />Range Section <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE—L-ff BOREHOLE—L—0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0EA <br />/MUD ROTARY DEPTH OF GROUT SL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />` <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 00 HAND AUGER GROUT SPECIFICATIONS c f/1+ltrfl%�ds/Sr�rir <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted I <br />Grout Inspection By_ <br />Destruction Insoection <br />COMMENTS / CONDITION <br />Title/Company %N&iriWf <br />713147 <br />DEPARTMENT USE ONLY <br />Date <br />�-! L-07 <br />)ate Issued 6&&.) Area_ <br />Inspection B' Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />RE�C''D, BY <br />DATE PERMIT / SERVICE REQUEST# <br />INVOICE <br />SR# 77 <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac ment doc_ <br />EHD 29-02-001 web <br />6/22/04 <br />