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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 />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 />Ci+y R ANT- v411 : k.., £' Assessors EAST WELL Location EAST or- I j S. wasnn wiy Cross Street Ai lt K 4- 54-: City 5 roc.K ro Ai Zip 752P 5 Parcel# 13I ^07 A T TN : R ( Ohl*/ / PROPERTY e . 951. <br />Owner <br /> <br />‘-; F 5 1' c.ctSpwaddress 5 415 0A A 0 p city S Ter Ifro.4 Zip Phone* 957-8-141 <br />C-57 Contractor GrEy:, Dr ; Address CI 5 0 /44W e. R ts. 13 13 cityPIAt 4-iiNLZip/Y5.5:3 Lic# 651 Ye) 1Phone# (9z5) 5/ 3 .-5,5 <br />AG. r4 Address 3 7 514 A iv R0.city STol 6-rowLic# 65 0 ZZ 7 Phonekt Q5) Yc 7 -/ o 0 to <br /> Township Range Section <br />i•giy,f04 <br />SITE <br />MITIGATION <br />UNIT IV <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />>fcNEW WELL / BORING <br />OvOIL BORING # CP <br />ELL # <br />0 *Other <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />fl EXTRACTION <br />1:IA1R HAMMER/DRIVEN <br />0 VAPOR <br />El MUD ROTARY <br />O AIR SPARGE/ OZONE PUSH POINT (GP or <br />*OIL BORING HAND AUGER <br />0 OTHER: ['OTHER <br />COMMENTS: <br />C.) <br />01,7e,0 05 /Z3101 a <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Phil U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: MAE <br />CASING THICKNESS NO TYPE OF CASING: 0 STEEL fl PVC fl OTHER: <br />DEPTH OF OF GROUT SEAL / # TREMIE TYPE TO BE USED: fl AUGERS AI-10SE <br />ROUT SEAL PUMPED:XYAs No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 3 <br />GROUT SPECIFICATIONS rorrIllvo Ty p C it <br />APPROX. BORING DEPTH ILO l U BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED N/1.4 (if YES, list specifications in comment section) <br />COMMENTS: sEelipr•aveb 1,4 AK PM tv Arru) 1)/15/ 05 ics tvi'eb ‘40 11( "Lie.) <br />GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />c1'1-4 1 cPT-l.)cp T.1 0 DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />4 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 S ate Laws. <br />Signed x A Title/Company r Pc.ip 1;7 / .6 . <br />Print Name TN\ ( V Q 11,9 A Date 06/ Z3/ /0 (41, <br />DEPARTMENT USE ONLY <br />Ga SAC- loog SITE MAP IN UNIT IV FILE, ADDRESS: /0"( Ce),/foit. <br />WORK PLAN DATED: <br />it.)42/3.0h Date Issued 6/2 7/04, <br />Grout Inspection By *GA/ Date i'A q"c2 Final Inspection By 11/4 /4 <br />Destruction Inspection By Date <br />Application Accepted By Area / ri,S"? <br />Date d770_17DeFr" <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMI - * •UEST # INVOICE <br />350( 1N 14) sr. Z79- ` <br />7 Otir4 0 4i I i - # 00 Lt 7 2 l 9 <br />C-57 <br /> <br />WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroac ment doc <br /> <br />EHD 29-02-001 <br />6/22/04