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a San Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MW <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 ofSanJoaquin County Environmental Health Department. <br /> �2NZ S. C�� a-G 00 L l -1 S Parcel#Assessors �'-r�� <br /> WELL Location ^Cross Street v City Zip 0 <br /> PROPE <br /> Owner N� �`�u{.��� 1 Address Vl 1(��,2 j�U �(Q�,,,Cpity�� ZipaC32&hone# -" J� <br /> C-57 Contractor Address Cit Zi �C# 1 hone# l <br /> Consultant/Sub Cntr Gi Address4IAacIMkV-/ City C05YA G-kLic# Phone# 2�Jd-�(r}� <br /> GIS Coordinates:X 37 ��1_Z'o " ,Y W ��?'4145 <br /> 1 <br /> ,Township ! J Range Section 2-3 <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> a SOIL BORING# ®OVER-BORE. DIAMETER <br /> WELL# ®PRESSURE GROUT <br /> 'd"Other GROUT SPECIFICATIONS <br /> COMMENTS: `' 'ez � � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p g <br /> �IIVIONITORING Q HOLLOW STEM DIA.OF BOREHOLEjCft®MULTIPLE CASINGS ®MULTI-LEVEL WELL CASING DIA: <br /> o EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS' M 0 TYPE OF CASING: ®STEEL V-PVC ®OTHER: <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL 3s TREMIE TYPE TO BE USED: ®AUGERS ®HOSE <br /> ®AIR SPARGE/OZONE ®PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes No (NOTE: MAXIM M FREE-FALL DEPT IS 30') <br /> ®SOIL BORING Q HAND AUG_ER GROUT SPECIFICATIONS <br /> ®OTHER: 'OTHER n►V APPROX.BORING DEPTH ®BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanrs ules and R ions,and all applicable California State Laws. r <br /> Signed x Title/Company tfx,, PAYMENT <br /> Print Name Date ' G� V RE <br /> DEPARTMENT USE ONLY JAN 17 2007 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: sm jaA6164W COUNTY <br /> WORK PLAN DATED: FNVIRONMENTAL <br /> / HEALTHRTMENT <br /> Application Accepted By sof A) V&44-0 —Date Issued_ �k _e� <br /> 7! ®� Area <br /> Grout Inspection By P '-'� .Date Y L-7 0 Final Inspection By ate l -o <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: v w'77 <br /> ACCOUNTING ONLY: AID# FAC# <br /> L;�q <br /> ODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ?/ ,gf g ?_0a d23g9 - 1,12107 SR# 190 Ll 2, <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 />