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San Joaquin County <br />Environmental Health Departmentso ITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9520C9 <br />���SVII GATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/eh&,"l's 41, O <br />Well Permit Application Fs, <br />W"411101#44 <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 />2 �� q Assessors <br />WELL Location ) OCcr' I S r�4GN Cross Street �iW1 q� City �Oc-V-+DY� Zip CIS 2-52 Parcel# 179 ^ (l OZ4 <br />PROPERTY C`� eh+ 7t7-7 µ(p5-(�O7 <br />Owner Mpr!�aV-L - KkarG% Address 20 J-\ob�\e- \-MCv, City C,TZipg5631 Phone# 3 <br />C-57Contractor \/5W'Dr'1111ir1ddress R0.r3c. 1,7_L�_City. LvciI Zip9521!1!Lic#TZ09DNPhone#_(t0CJ�3(oq--C <br />R fAn nt /Sub Cntr [-ICQ1gAjCa1 -VPGh1'11 C S Address t lDt �1 V'Q2�� City N� & AO�Lic# — Phone# 622 - <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />,ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) g DESTRUCTION (choose type below) <br />a SOIL BORING # a OVER -BORE. DIAMETER <br />I,WELL # -1W - I t awl - 01 ` E LJ 1 to gVj3'i EW 101 0 EW ID -3 j 0 PRESSURE GROUT <br />a •Other s, A5- I GROUT SPECIFICATIONS <br />COMMENTS: see- aftac --d k 0o v- lL Pkx� :June- q , 20D�P <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING 9 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />EXTRACTION 00) a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />$AIR SPARGE/ OZONEC�h PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />g,OTHER: LZ n OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: s2e 0.-ytcL VNeA W\DSK- Cb_Ae6 -wrg. C\, ZOC)�O <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 Ordinance, Rrl�jd'Regulations, and all a licable California State Laws. <br />Signed xapplicable <br />Print Name Date 1C? IT - j <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2 9 6o I Loom i 5 'Road <br />WORK PLAN DATED::/ Jun e- q 200(, <br />Application Accepted By V l Gt o Y 1 a L. Mc- ea Y� n gtir Date Issued J U n G 13, ZOO^% Area i 4- S q <br />s ! �r� �.ar hzcc Date 7 - �j-L 1 Final Inspection By \j: r y,,a lit'd y'f Yum Date %' I ? 6' <br />Grout Inspection By � , r:'r/rr,� `� <br />Destruction Inspection By Date <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />INVOICE <br />350/3 <br />2ss;oo X374. ov <br />/-tR# <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permYchment doc <br />EHD 29-02-001 <br />6/22/04 <br />