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.oPquiN o <br />• SAN JOAQUIN COUNTY <br />_ rG ENVIRONMENTAL HEALTH DEPARTMENT <br />y• � <br />600 East Main Street, Stockton, CA 95202-3029 <br />`P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: ;. w'or.s <,v <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 />F' Gi✓ C� Assessor' r� <br />Well Location / 77 Cross Street City CXL3 Zip /Parcel # J "'� <br />Property / 1 ��� 9 f flJ phone <br />Owner 15 lf^ ✓� C///✓ «A�dd/ZSs /�/O ��,, It/j�J`2 EC% ;ty Lya / zip / P �l� —.?Cq'6 <br />C-57 Contractor eLAL- 1)"" t � Address ISS% 11 aw'� A6 City��R �� F aip "ll Yic # _ �ih',onee <br />Consultant/Sub Cntr IV C -C � EN�Address City Lic # Phone '?/'? —J-4� <br />GIS Coordinates: X e Pe Y /02/ 4eY 0,1 , Township a ,`� Range SectiorP��� 3�U�� <br />WORK TO BE PERFORMED: <br />❑ NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />❑ SOIL BORING# <br />❑ WELL # <br />❑ *OTHER <br />vve <br />41111-lcr-- <br />DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS jf <br />❑ EXPLOSIVES DETONATING CARD <br />�rclhi �wiio weX l� /,� e✓ S✓c <br />e^ <br />TYPE OF WELL INSTALLATION YYPE CONSTRUCTION SPECIFICATIONS �7 <br />❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE '_,r_/ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS s'C� �0'*0�Vt <br />PE OF CASING: ❑ STEEL VC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL � A7REMIE TYPE TO BE USED ❑ AUGERS �jHOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT) GROUT SEAL PUMPED Yes El No (NOTE: MAXIMUM FREE -FALL DEPTH/ IS 30') <br />❑ SOIL BORING [I HAND AUGER GROUT SPECIFICATIONSC� M��� `'~ <br />❑ OTHER: _ ❑ OTHER: _ _ APPROX. BORING DEPTH ❑ 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 />I hereby certify that I have <br />Regulations, and all applic <br />Signed l�l/!//( �- <br />Print Name A/, All, <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />ppiication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Laws. s,�_i/✓/ryeit/�/i✓EF/Z . <br />Title/Company.S,v ivulvv 6' <br />L DL L <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />✓1/W-4i_�- <br />DEPARTMENT USE ONLY <br />Date 63�/a ' <br />DATE//I��SSSUED �C/--;wD AREA <br />FINAL INSPECTION BY /�oE�DATE 61_0'11�0 <br />DATE d/f/ 110 <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />4,4, -/'z <br />:50fV00o-7$q <br />LAS <br />(0/y 11 p <br />SR# 6' / <br />C-57 WC <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 10/28/09 WELL PERMIT APP <br />