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San Joaquin County <br />�oAQu.y �0 9 tY <br />Environmental Health Department F� ASS l <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 IOw 06 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd�tiF� <br />• 4t/FOR Well Permit Application <br />— T <br />NN S N <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />WELL Location L`l C R <br />ya�ak Cross Street City ' Zip <br />Assessors <br />Parcel# U`1l - (ci 30 3 2- <br />`jr- �c Yr�� fa <br />b\If C \ <br />REC'D BY <br />DATE UEST # <br />PROPERTY <br />Owner R �c�c�k; r� %-'.cin <br />is 'ac>x y Q-'` `1 <br />�.�ir�ddress <br />City f'\ Cf G SLg Zip`s <br />C-67 Contractor s �a.a <br />Q`` �k r\;Address 3i� 3 o,�e� <br />city � rZip`1 1-;,Lic# <br />Phone# (`libi lc jY ' ttb`7 <br />Consultant I Sub Cntr <br />Address_3ot-1 tom,\ <br />City IAC. 1v7 Lic#` <br />_Phone# ( 'Ail, SSlol Oyc)a <br />GIS Coordinates: X <br />'Y Township <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />J;NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />it.SOIL BORING # AI. 3 0 OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT <br />0 `Other GROUT SPECIFICATIONS <br />COMMEN <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 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 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS QSj4A\c vim\ <br />0 OTHER: 0 OTHER S`„ 1 L APPROX. BORING DEPTH_ tc.r.' _ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMM <br />S -i <br />Mo N71o'"k s—Cl'a - fes- 9-c:e tz— COA <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT CfR 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 x Title/Company `� 0s� t e -Sr <br />Print Name Date Ifi�T(jy. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, AQDRESS: <br />WORK PLAN DATED: 5 i ) O y <br />Application Accepted By Date Issued -Z_ (3 Area _ <br />Grout Inspection BDate Z 2 O Final Inspection By 1�-vi.w�w� Date 2 b !i,6, <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE UEST # <br />INVOICE <br />o0 <br />61 Z307- <br />z SR# S ssb'6 <br />C-57_ W(_ -WAIVER- C-57 Letter of Authorization to sign permit_ Encr <br />EHD 29-02-001 <br />6/22/04 <br />