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San Joaquin County <br />Environmental Health Department <br />600 East 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 />QRIGINAL <br />1 IGAT)ON <br />SAN,, N IT W8 <br />HENI�0'N' <br />H <br />6'1 'At <br />MRNT <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 // 5-3a Gam%. .E-/Zl N;"PW,- 1Vross Street City SraKTaQ Zip _Parcel* <br />PROPERTY �L/ A40Y 2 i/ / � 4�lOL Q . ,C <br />Owner ,(�i{,�/L�. Addressd% G• /`7R�''` City / ZipTJ Phone# p CJ <br />C-57 Contractor �✓rJo�t�ff� Address SSS0 ei C—; Bo%lj City Rio Y/STaI zip `?3/S7/Lic#7/0o7/Phone# 7077< jbo <br />Consultant / Sub Cntr 4 -re- /�SKSvc Iit�CS Address <br />C///7 Lon C- ?,4L- ► City MaDESr Lic# Phone# 579 2Z Z <br />GIS Coordinates: X 356 - c S! Y 12J'(l S 6 , Township Range Section <br />W BE PERFORMED: <br />0 NEW WEL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND AUGER, OTHER*) 0 DESTRUCTION (choose type below) f <br />BORING # / 0 OVER -BORE. DIAMETER lJ� <br />0 WELL # ,�11 C �l D� 0 PRESSURE GROUT Gj <br />0 *Other ��� GROUT SPECIFICATIONS a <br />COMMENTS: <br />TYPE OF WELL <br />ONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />0 OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />EF67OLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: g-'Yres 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER APPROX. BORING DEPTH eOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />FEE I FO <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />JO <br />REC'D BY <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />INVOICE <br />I hereby certify that <br />I have prep Pe s application and that the work will be done in accordance with San Joaquin <br />County Ordinanc <br />es a egulations, and all applicable California State Laws. <br />�c/� / SR Z' , <br />"9 7 <br />Signed x <br />Title/Company <br />Print Name d�� <br />�% E� Date <br />DEPARTMENT USE ONLY <br />11530 Ste- <br />SITE MAP IN UNIT IV <br />FILE, ADD R ,�.--� <br />WORK PLAN DATED: <br />Xn <br />v Area O <br />Application Accepted By <br />Date Issued <br />Grout Inspection By <br />Date Final Inspection By Date 22 U <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE I FO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT /SE/RVI UEST # <br />INVOICE <br />U 4 to <br />V4 <br />�c/� / SR Z' , <br />"9 7 <br />C-57 ✓ WC✓ -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc <br />EHD 29-02-001 WEB��� <br />9/11/2007 <br />