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San Joaquin County <br />Environmental Health Department I <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ((;; /D <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd Er✓ F� �Zf4'l0N <br />p�✓,0,�p,UN <br />Well Permit Application FR,tj /✓T <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RI/IFS' <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 = ., - c� 2 » ; Cross StreetAssessors <br />City��s -Zip Parcel# <br />PROPERTY �\ <br />Owner L -� c Si `err i-1 cr-Address_ IS -Ac.... N C }cry Zip `l`:� 2� Phone# ` <br />C-57 Contractor <br />- Address Cit <br />c•Celt y� acv ZiP�ilic# il'',,phone# `lib t� -i1b`t <br />Consultant / Sub CntrSL r S y, �« K. Address__ <br />3 ' • � t -+i � <.� � City Lic# $ � � �i 4 ' 15hone# � i <br />GIS Coordinates: X Y <br />T- 1\11 . J <br />,Township Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) p DESTRUCTION (choose type below) rn' <br />SOIL BORING # j <br />0 WELL # 0 OVER -BORE. DIAMETER <br />0 *Other a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS:_ <br />-t--� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: <br />0 VAPOR a STEEL 0 PVC Q OTHER: <br />MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: o AUGERS <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: HOSE <br />SOIL BORING � Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />A 0 HAND AUGER GROUT SPECIFICATIONS <br />Q OTHER: n OTHER APPROX. BORING DEPTH L <br />BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED(if YES, list specifications in comment section) <br />COMMENTS: IJO hA rad C' ` <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 x �' (� <br />—"—�'' Title/Company_ <br />Print Name <br />Date_ ? 15 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z c(b �, �y , , I l� <br />WORK PLAN DATED: <br />Application Accepted By_ w� Date Issued 2 _/ I O <br />Grout Inspection By Area <br />Date Final Inspection By Date p6 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />QUEST # INVOICE <br />3S t" i -o0 6`(Z3ef z SR <br />C-57_ WC --WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />