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o � San Joaquin Count <br /> q Y <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 SanJoaquinCounty Environmental <br /> Health Department. <br /> Assessors <br /> WELL Location '�l "'�`'U�R4-cross Street V City C"'v �""1Zip Parcel#PROP <br /> Owner TYpp�� r �,�V) 6-1 ` �U Cit 3L!��Zi '"`'&hone# <br /> Owner �V� ���►rr1 (/`V'��� Address (�• y p �� /� <br /> C-57 Contractor 'l n -DI'11 Address U City `kyl� Zip �Lic#�7ZPhone# lQS9 -11M <br /> Consultant/Sub Cntr C`a- Address , S �uC City L h Lic# Phone# L L� -91 v(D <br /> GIS Coordinates:X 3155oz 6 Y 12111V0.4's Township I Range U Section <br /> WORK TO BE PERFORMED: <br /> ffiEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORINGa OVER-BORE. DIAMETER <br /> &NELL# )� ?^1�Pr- a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING a HOLLOW STEM DIA.OF BOREHOLE U MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SW D TYPE OF CASING: a STEEL MVC a OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> p AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: `%Yes a No (NOTE: MAXrp!yne'j- <br /> UM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AU ER GROUT SPECIFICATIONS - fi IG <br /> OTHER: OTHER \O, APPROX.BORING DEPTH 1001 a BOLTED TRAFFIC BOX or 'STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ordinance7rfulesand Regul ons,and all applicable California State Laws, <br /> Signed x Title/Company C'a4SU l� <br /> 9 <br /> t [ <br /> Print Name V C ` Date <br /> D PARTMENT USE ONLY RECEIVED <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 'A N " 2007 <br /> WORK PLAN DATED: <br /> /JJ , SAN JOAQUIN COUNTY <br /> Application Accepted By w �+r�' �u " t VOW Date Issued V1 7 7 Area ENVIRONMENTAL <br /> Grout Inspection By Date Final Inspection By Date HEALTH DEPARTMENT <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a3 9 9 ��7 SR#��q y 155'91 <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 />