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-an Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />ORIGINAL <br />Mh,GAEIaN <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd NOV 1 9 200PJNIT IV <br />Well Permit Application ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 33Y �u5� Nla�✓1 Si Cross Street %Z i Pon Zi S' Assessors <br />-City p � �6�0 Parcel# -2 61- 15o- all- <br />PROPERTY <br />iZ <br />PROPERTY <br />Owner Chevron FAA C Address P 0.f30X 60/,7 --City San Pc,,morjZip 9y583 Phone# 9d5 --8`f,2 -7EE 9 <br />AID# <br />- X13-5800 <br />C-57 Contractor ro ( tyle Address / J Q HOWe Rd. CityAc r ji*L Zip9j/SS3 Lic# 8 165Phone# 9Q5aj <br />PE CODES <br />/� Or <br />Consultant / Sub Cntr 699 Address,2000 */QCity OSeViNB Lic# Phone#F1 1j <br />AMOUNT REMITTED <br />GIS Coordinates: X Y Township Range Section <br />REC'D BY <br />WORK TO BE PERFORMED: <br />INVOICE <br />NEW WELL / BORING (CPT, GEOPROB HY <br />, DROPUNCH, HAND -AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />J SOIL BORING # VO -Z 3 <br />`t <br />DV �t y V d- [] OVER BORE. DIAMETER <br />30 // 7n <br />0 WELL # [] PRESSURE GROUT <br />SR# 003"26 72 <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />() MONITORING [] HOLLOW STEM DIA. OF BOREHOLE e [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />y <br />C <br />() EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESSA4M TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br />VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL oft TREMIE TYPE TO BE USED: GAUGERS [] HOSE <br />[] AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: [] Yes I No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS TA (fie 7/01- Pc,r -Ll an d Ce men -t <br />0 OTHER: [] OTHER APPROX. BORING DEPTH C 4 [] BOLTED TRAFFIC BOX or d STOVE PIPE <br />CONDUCTOR CASING PROPOSED 11/D (if YES, list specifications in comment section) <br />v� <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 />n <br />Signed x � A49� Title/Company Sta+� 17&016! tiSb / C K A <br />Print Named ffio-m M art; ne 27 Date Il �l SAO <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 334 Ea S } Mai n oSf• IR t jeo n <br />WORK PLAN DATED: i�.o ber 1, a 0 0'1 <br />Application Accepted By Vi e,+nrizMG rfe- V Date Issued Area 14$ <br />Grout Inspection By V r+o,r% &- ME C(k,r Date 1- 17 -0 8 Final Inspection By 1 i tn,hze."nj_�`iY.Ile-nate !- / 7 - d 0 <br />Destruction Inspection By 1 Date ,����- <br />COMMENTS / CONDITIONS: p1 VD /!/� d V/0-1. V 1p , 2 - VF -3 <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER EST # <br />INVOICE <br />35O i <br />89. ov <br />6 p00 <br />30 // 7n <br />SR# 003"26 72 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ oc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />