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Rr IGINAL <br />San Joaquin County <br />_.. ? nvironmental Health Department TE J <br />4 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ,M/Q�IQ <br />.: (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd - CM.7V,1I'j'l� I V I6 <br />�.•...-- .... ,P� ems''ERA777- T H <br />q��FOR� Well Permit ApplicationN <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED flCL�s <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 �� _T Cross Street v 9�City Zip Parcel# c Ky <br />PROPERTY e /4 K ZOwner lCity pP 9 <br />Phone# ?- T�Y-1Address <br />C-57 Contractor Cs� ��_ Address �E�-Z ?�� �'-�C City 444'r1& rt �ip�ST`�.� Lic# 7T7s., Phone# <br />/sy Y?�v FE <br />Consultant/ Sub Cntr sEC�iP �" h-A��Address I%� Y�'t'� �mCity �E+^��0 Lic# Phone# 5` <br />GIS Coordinates: X <br />Y , Township Range <br />Section <br />WORK TO BE PERFORMED: <br />g'NEW WELL / BORING (CPT, GEOPROBE, HYDROPU NCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING`# 0 OVER -BORE. DIAMETER <br />;RWELL # La L 0 PRESSURE GROUT <br />0 *Other 1 11 GROUT SPECIFICATIONS % <br />COMMENTS: jir-�� is" Ns.Q r,� �.:.. f �`f �dyr. �cw�rsTc/- C4 T �%cS' / �P rr �4.� r%�r/ �/re'`/ <br />J <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U:MONITORING gl-iOLLOW STEM DIA. OF BOREHOLE J 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS, . yG. TYPE OF CASING: 0 STEEL / },PVC 0 OTHER: <br />.Vf1z 1 !s' <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL;Pro z� - Wit!r" <br />TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: , Yes OTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER:_0 OTHER <br />COMMENTS <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH '&W -7z 3r cs� XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED)�GS (if YES, list specifications in comment section) <br />-t2 f ��. �r �' f 7s /e „ <br />00 <br />4_1 <br />K <br />d <br />�1r>Cf l,,71I"-iL �<!rc 5 FCe� s/ <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 T <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x // �.�� Title/Company / <br />Print Name iL,,ckar`at1 /dr (fres" Date <br />DEPARTMENT USE ONLY jj�� <br />SITE MAP IN UNIT IV FILE, ADDRESS: � &�` <br />WORK PLAN DATED: % ''OS <br />Application Accepted By Date Issued —Area 46 <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />ECK # <br />REC'D BY <br />DATE PER EQUEST # <br />INVOICE <br />Q <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit _Ehvroaektme doc_ <br />EHD 29-02-001 <br />6/22/04 i <br />