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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 />t 11rce y 1&!5 ` C��✓d Cs� Assessors 9? <br />WELL Location 6 fir` Cross Street '� City Zip Parcel# ®/ % �� �j Z <br />NiGG v.4i/G iPROP <br />ER'OL/E� /G`y <br />OwnerAddress L % Cit s�i�5"_ <br />1 09 <br />/ v� 31- Rfpv`Hv Cope Do*%"* '7/ 7 S!o <br />C-57 ContractorC/1T Address,?C "le City Zip Lic# Phone# pf6 �"6 S'� /!� 9 <br />Consultant/ Sub Cntr Address City Lic# Phone# <br />�dRls% 9 �� <br />GIS Coordinates: X 'Y Township -2: Range g Section fj <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) DESTRUCTION (choose type below) <br />® SOIL BORING # a OVER -BORE. DIAMETER <br />VWELL # //0 , ?72 0 a PRESSURE GROUT <br />-" 8 *Other ��+ / GROUT SPECIFICATION <br />COMMENTS: /IIC� %riP I@ J�®@ d C 43 /�lJi%� l✓ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />y�MONITORING HOLLOW STEM DIA. OF BOREHOLE° ® MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />l ®' EXTRACTION ® AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL ® PVC a OTHER: ^1✓ 14 ' <br />® VAPOR ® MUD ROTARY DEPTH OF GROUT SEAL 3F7 TREMIE TYPE TO BE USED: D AUGERS a HOSE <br />0 AIR SPARGE/ OZONE ® PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') r <br />p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS N�CR7 65-1"EA17ejPt4eek / •' Ems✓%(fjt/�lt` <br />® OTHER: ® OTHER APPROX. BO G/DDETH _ n BOLT RAFFFIIC BOX or ® STOVE PIPE <br />N! , y CONDUCTO ASIAIG PR S [i / °� �n (if � , s specifications in comment section) <br />COMMENTS. XE -f2- 0�G�f %'R E- fa��i ,1�`�`"1a• <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, an all applicable California State Laws. <br />Signed Title/Company SE''���r �/�l//✓E ®-fGL�O W'�1�,��� <br />-.t J c- <br />PrintName !" �� L ®GG- Date q/6 ?L <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued Area <br />Grout Inspection B 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 # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />S R# <br />C-57 WC --WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />