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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />E D <br />JU�ITIGf <br />�oa/ <br />ENVIE TH <br />PERM T/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 />t — Assessors <br />WELL Location614 4 S, L1 ni 01 r) 5' r --C"— �' Cross Street W. SCc�tI S City STPj14-0 J Zip Cf 5 2v3 Parcel* 147— 00 7 <br />PROPERTYy {{ Riva <br />` i /� 1 G <br />Owner y a in 5� I o260 Address,S9?14 <V ` 01 b iya City t"leGS(�N►%Y1Zip Iii 2 i <br />_ �- to Phone# ! s bb <br />C-57 Contractor kmUj Gtr QW, Address t['j.�?S11tiy) Cit clu�l Zi �Lic#�SOZLJPhone# —It)O <br />Consultant / Sub Cntr Address 03 7 SlyA w WQ City S Lic# 71 Phone# Z to%— I b o I <br />GIS Coordinates: X Y Township Range Section <br />PE CODES <br />WORK TO BE PERFORMED: <br />AMOUNT REMITTED <br />jJEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />/ ` SOIL BORING <br />REC'D BY <br /># a OVER -BORE. DIAMETER <br />PERMIT / # <br />�] WELL # 0 PRESSURE GROUT <br />ffipa. 21� <br />* 0 *Other GROUT SPECIFICATIONS <br />F <br />COMMENTS: <br />7 I5 0-5 <br />SR# q3 D -7 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: } <br />_►�V <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Al f r!�- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ,$AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes _a --No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �h j <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 3 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />S <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 />CounOrdinances, Rules and Regulations, and all applicable California State Laws. <br />% q n <br />Signedx Title/Company_ ,f�10 1-S� ! Ilii ll'CA1AC.AI-F��1 �91TP�i) <br />Print Name 1 1 (� y1 1 { 1 Q, yK �j (ti (� Date <br />DEPARTMENT USE ONLY <br />SITE MAP X33 <br />IN UNIT IV FILEA DR SS, <br />WORK PLAN DATED: F <br />Application Accepted By Date Issued rS U S Area <br />_ <br />Grout Inspection By. `" M Date C inal Inspection By 6 Date ;W <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: / <br />ACCOUNTING ONLY: AID# FAC# Jnr <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / # <br />INVOICE <br />ffipa. 21� <br />-)CSCIC� - <br />-' 3 (o� <br />7 <br />7 I5 0-5 <br />SR# q3 D -7 <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 />