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• FILE COPY <br /> San Joaquin County SITE <br /> Environmental Health Department <br /> A 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> ' <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgON,.org/ehd UNIT IV <br /> p <br /> t o ' 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 9-1715.3 and the Standards e a^fAssessors <br /> dk;^in County Environmental Health Department. <br /> (98SSW 4r�f (4 QdCrossStreet HoOSe Q((W1City Tr Zip 9539/ parcel# �.c9-0140 A <br /> WELL Location t�" q <br /> PROPERT�Y`� «» 2n' F�ower�T✓.aty (� !Mor Zip/ SO Phone# 40 <br /> Owner / uel E�f4S Address» p /A <br /> ' P().B oX 7�6 city{�C,[1Ll—Zip bill Lic# 2o90VPhonet,(9/6)T/7-w0o <br /> C-67 ContractorVSW Drd(tA- Ac Address Phone# 2. q�0 23 <br /> ''''11 r !/-,1 y-772�' <br /> ' <br /> Consultant/Sub Cntrwa1�icc- 5106.Address�T(0 IRI (/eivae�s(� ty- /to <br /> GIS Coordinates:X -Mb ,Y [.� <br /> Township O�J Range 45 Section <br /> WORK TO BE PERFORMED: STRUCT <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') UU OEVER BORE.I DIAMETER_(choose type below <br /> SOIL BORINr�# -oaf a PRESSURE GROUT <br /> �'WELL#MW-D�� /`�'D 3,M GROUT SPECIFICATIONS <br /> 'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I/ <br /> MONITORING '$',HOLLOW STEM DIA.OF BOREHOLE-8L O MULTIPLE CASINGS II MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSSLk 40/ TYPE OF CASING: a STEEL XVC a OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �o TREMIE TYPE TO BE USED: )*UGERS a HOSE <br /> a AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED:A'l'es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> p SOIL BORING UHANDAUGER GROUT SPECIFICATIONS meat cemcgt <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH 157' 0 BOLTED TRAFFIC BOX or)PTOVE PIPE <br /> CONDUCTOR CASING PROPOSED nAb (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 aInn�d Regulations,and all applicable California State Laws.9 1 1 t <br /> Signed x � �`^—dZh-� Title/Company fey j 61�l r*S-f /� acG-kit h r 4 Af 50C , <br /> Print Name Fred W. 634 4.5 Date Awigst <br /> DEPARTMENT USE ONLY <br /> 2 -6S <br /> SITE MAP IN UNIT IV FILE, ADDRESS: la SOd " <br /> WORK PLAN DATED: -Or <br /> Application Accepted By Date Issued O 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 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PER►#T I SERVICE REQUEST# INVOICE <br /> ay.o h1 �9. DOGS( �Z� SR# DO`f3g56 <br /> C-57_ WC ✓WAIVER_ C-57 Letter of Authorization to sign permit ✓Enc�lnent doc <br /> EHD 29-02-001 <br /> 6/22/04 �h <br />