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San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <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 />Assessors <br />City 5 -foci< fov‘ Zip 192,7- Parcel# ?/ô <br />PROPERTY <br />Owner Rai 5cA5litfi-o/Cfark f- Address 3°1 $. A Q ea %rut $4. City Sf0C,k -6-% Zip 15 703 Phone# 101 -1149 01133 <br />C-57 Contractor V 1•1/J D e IV; Address Po 1301 q7 0 City Lo d Lic,# 7 7 °90 41 Phone# Y'- ?h00 <br />Consultant / Sub Cntr rou's 4 Av•allc; ) Address 17 II ma; s+ • City Ec cq toi,‘ Lic# 6 Phone# g" 3 8 cig es- <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) I] DESTRUCTION (choose type below) <br />31,SOIL BORING # C-13, \ +.-2-- 0 OVER-BORE. DIAMETER c)() <br />is.vvELL # AA t4 Ii 13 / itAw I g c itnv'lql) 4 ct, 4.) a PRESSURE GROUT v.-.)..) <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: 6 <br />INSTALLATION TYPE <br />itHOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />liMUD ROTARY <br />ONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Kes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS .A.1 e.c4 (./-ro <br />1:1 OTHER APPROX. BORING DEPTH IS0?/3072 3/ 300` a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section)_D <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 />Signed x QC*6 Title/Company 5+4c- treolo7is +/Ere0 e '0 4001/ <br />) <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />gzco rt) 447-07. <br /> <br />Application Accepted By CNA.A.Anc dr-t <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br />Date loft 15/0 Final Inspection By <br />Date <br /> <br />glb <br />••• <br />Area <br />Date <br /> <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# FAC# 5 -"-R V 0 fi/ 537_:-.4 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT - ; • - , INVOICE <br />3 5-0 I isAk•co OLV SR# 5 t s 3 3 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />RECER1,,QTiv <br />AUG -4, <br />MI III TION <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />WELL Location z 00 AL 1-1 4.7 kw 0,1 GI °I Cross Street FO? io1v10 )1 <br />TYPE OF WELL <br />AMONITORING <br />a EXTRACTION <br />fl VAPOR <br />0 AIR SPARGE/ 0 <br />?f,SOIL BORING <br />fl OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE "//O "0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 7 ' <br />CASING THICKNESS Scl • 0 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />DEPTH OF GROUT SEAL 13'0 240- TREMIE TYPE TO BE USED: -AAUGERS 0 HOSE <br />Print Name <br />EHD 29-02-001web <br />6/22/04