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San Joaquin County <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 />SITE <br />FEB 0 9VATIGATION <br />ENVIRONMENT 4M IT IV <br />PERMIT <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 anr_40e Standards of San Joaquin County Environmental Health Department. <br />r r W . Wusl�in �Da1 f- Assessors . <br />WELL Location iYA 0+ STOC ClOV1 Cross Street NgMq j&jvr,City Zip Parcel# i�5-D3p_�10 <br />PROPERY 1kCl <br />Owner 0✓+ of C4OCrz1 Address X01 W . WS6rc jMn SI-. City S4tC44o/1 Zip 0 S X, I Phone# c09)qqr-Dot <br />C-57 Contractor. C4.16 �% 5; •.w'C� City_�n^r/wic`;.% <br />Consultant / Sub C <br />GIS Coordinates: <br />, Y , Township Range <br />Phone# 916 • W- 0 100 <br />Section <br />WORK TO BE PERFORMED: <br />�VNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL# T5/MW--ZO ; QL)iLI Qw8t) 0 PRESSURE GROUT <br />by *Other 5crnt_ T GROUT SPECIFICATIONS <br />COMMENTS: — <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />AMOUNT REMITTED <br />MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE IQ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 12 --Lo <br />a EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS G�h 40 TYPE OF CASING: 0 STEEL ,KPVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 16-49g6ttS�X TREMIE TYPE TO BE USED: 3CAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: KYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS NWk CCr%R.n} <br />0 OTHER: OTHER '5 ,^ t_ <br />APPROX. BORING DEPTH 75-- i10 XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 'I etlh00✓ <br />y ul GOVId l.(C+w <br />cta­-tvtU TD be IV6ktt PCf kQryi Gtw&ce <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 jind Regulations, and all applicable California State Laws. <br />sl �xo�o5lsi-� <br />Signed x Title/Company .9 0 <br />Print Name Date <br />DEPARTMENT USE ONLY ,n <br />SITE MAP IN UNIT IV FILE, ADDR SS: dLf S -r -r l,U <br />WORK PLAN DATED: 1012 r) 0 <br />Application Accepted By` Date Issued.% Area 7 <br />�Z <br />Grout Inspection By Date ( ) �J Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# I FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK It REC'D BY <br />DATE P T # INVOICE <br />;Z-C?-01� <br />t" <br />6/;40 I <br />�b s SR# �o /13 <br />C-57_ W(_ -WAIVER— C-57 Letter of Authorization to sign permit_ <br />EHD 29-02-001 <br />6/22/04 <br />