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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 />�D <br />VTE <br />FNVIRONPoL"Tjj[9?t ION <br />PFPMIT,�StP T IV <br />w <br />I <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 />PE CODES <br />Sidewalk Qf �elle5 A,r W. N mmerLcy� Assessors <br />WELL Location Cross Stree City 5}OCk+ny,,Zip A F aJ -A Parcel# <br />PROPERTY C -I <br />Owner r. � Address �f 2 ��1, EI Do wal, CityS4O e k -fQn Zi{fls20.2 Phone# ZO 9 - 93 7 '8 3 ¢9 <br />CH K# <br />/ `-A/ G to \ a <br />C-57 Contractor` ASCA216 �r.:�Address 3b3U. Oyre I t `city r vraZipaS �Lic#���SloPhone#�Q �,3����� <br />DATE <br />Consultant /Sub Cntr SAddress, \-+ \<A&�r� RI.0ityGor"*,Lic#65!�NggPhone <br />GIS Coordinates: X 63\NQWQt 'Y ;X\ 4 53LI k I Township Range Section <br />L;�S"v� <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) WDESTRUCTION (choose type b"w) <br />[] SOIL BORING # OVER -BORE. DIAMETER <br />0 WELL # O PRESSURE GROUT <br />(SR# 0052904 <br />0 *Other1I GROUT SPECIFICATIONS <br />COMMENTS: `oma ` ft -k) -Q- Gl.1X' I id— � i o r k <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING vq.Lt OLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 15d,, yl) TYPE OF CASING: 0 STEEL P�tVC 0 OTHER: <br />O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: O OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or O 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 Ordinances, Rules d Regulations, %nd all applicable California State Laws. <br />Signed x !� 1 Title/CompanyFr­n i,C'k- SGD` G:% 4't <br />Print NameF)rGl7� cSK1� �0_ _ _ _ Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: NOVO; <br />Application Accepted By V r c to r 1 A M,, t!4y--"Yl eu Date Issued 12-) 2 'Q Area <br />Grout Inspection By \/i6y8 , & MeeA Yina„ Date )2 - / 7--u7 Final Inspection By 1 Date / Z -/�- U 7 <br />Destruction Inspection By Vi G r Me- r 4 Date /2 - l'/ -Q 7 <br />COMMENTS / CONDITIONS: ��,S+Y U -+i Q (L Yil0Y1 �"F>7Y j� Wc' I J,L` ti1V - I <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CH K# <br />REC'D BY <br />DATE <br />P T # <br />INVOICE <br />L;�S"v� <br />Ga. <br />/.2-/1-a2 <br />(SR# 0052904 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permitDE 11_croachment doc_ <br />EIID29-02-001 WEB <br />9/11/2007 <br />