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San Joaquin County <br />Environmental Health Department <br />600 East 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 />Assesso <br />WELL Location C iQ� `G -(A��"c1oss Street '��% O City %A�y Zip 953 77 Parce # rs-2 5'3 0 3 O to <br />PROPER? ./C , �!✓®'f112a N�s�t�2EL%��S/�IJZ�i�s��Pshone# C®✓ jo6p �„y O b r. <br />OwnerC �Ee� p.�/GG/�,,�� qq U Eit'/� ET/NEi 33 .stV? 3'Secro <br />C-57 Contractor / /address / X � City Zip '.C# Phone A <br />J/��P� �°�✓//? AdEN� /c�✓� tr Lic# ' Phone# ®1.i� <br />Consultant/ r t� <br />GIS Coordinates: X67Y Township aru /0/ Range J Section <br />WORK TO BE PERFORMED: <br />NVREW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />0 WELL #- <br />0 "Other - <br />COMMENTS: O �Q h/ <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING HOLLOW STEM <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />G✓�e W �.s"E" Cur'.n e ✓ L <br />c <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: , <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 4 <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIO0 <br />0 OTHER: B OTHER APPROX. BORING DEP' <br />COMMENTS: <br />g0 TYPE OF CASING: 0 STEEL VVC ® OTHER: <br />T-40F'rTREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />es p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Regulations, and all applicable California State Laws. <br />Signed x.o�elo i Title/GompaTijr ,fes/✓/!/.Z� �i ✓s�//✓�Eie f i✓/`� f lJ2 /� <br />i` <br />Print Name 'Al 1"/e'l-1A eG e'lf /fou Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: &/9/07 <br />/ <br />Application Accepted By �P Date Issued ! ` Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />e-fSR# <br />C-57_ WC --WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD29-02-001 WEB <br />9/11/2007 <br />