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San Joaquin County <br />RcCE�VED <br />Environmental Health Department 2008 SITE <br />600 E. Main Street, Stockton, CA 95202-3029F ' 1 17NIT <br />ATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ IIP, mu"iT IV <br />Well Permit Application PER <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 />WELL Location 3 y , t ��Y D ��`: _ Cross Street City L.0 Zip `l`�> Parcel# Ca 1 S i `{ OG L <br />PROPERTY <br />Owners _s5� S Address \il5 c«.�c�,_.>crs�City l—ac\a Zip SS 2_4hone# <br />ZZ C-57 Contractor CSG S�c.,�. L�rt\`'A dress 3�p 3 Z C-�cc Cit c �a" ' '�J �' <br />y Zip`iS l-k2Lic# Phone#_ ��i� 1_3k <br />Consultant/ Sub CntrR(!—C ADtS Address ``, <br />o City Sc �}o Lic# Phone# `i1�, . caS� . ptly ext <br />tla5��1 t\V 3Alt <br />GIS Coordinates: X Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />PE CODES <br />0 NEW WELL / BORING <br />(CPT, GEOPROBE, <br />HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />ILSOIL BORING # OC' —r <br />0 OVER -BORE. DIAMETER <br />0 WELL # <br />(j 2-2 F Z-4/ A <br />0 PRESSURE GROUT <br />0 *Other <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE 7-" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: )KYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS ( k� 3 --\M ) <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH �J�' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED 1J C (if YES, list specifications in comment section) <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 />r\ <br />Signed xTitle/Company Sxr�: ccl Q�ot `�C;St <br />Print Name ^C OY1N�_ �(`cw�1) Date I � � ( a <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE,DD <br />WORK PLAN DATED: / /rJ <br />Application Accepted By Date Issued �� / Area <br />Grout Inspection By Date 3 b Final Inspection By Date <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 PERMIT / SERVICE REQUEST # <br />INVOICE <br />p <br />10 t^ <br />(j 2-2 F Z-4/ A <br />u S R# <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 web <br />6/22/04 <br />