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Final Inspection Date <br />Date <br />WORK PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />DITIONS: <br />I-10-0.5 Area c96 JV <br />FILE COPY <br />San Joaquin County REcEllw <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.oraleh <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />Well Permit Application ENVIRONj ciJC)AQUIN co! :E NNTA0L 5HEA <br />2,07NDITLGATION <br />Environmental Health Department <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 />Assessors <br />WELL Location 75-05- Cross Street Mc IA City Sroc4.&-1 Zip 9 5-Z/0 Parcel# (DC o - Or <br />PROPERTY <br />Owner hod,' Glyaked 5eite,r1 hisPicrAddress /SOS e. Wee_ er City Lod; Zip 5'$2Y0 Phone# (20F) 33/ ?LIS' <br />C-57 Contractor rise.4.42,--7-cf.v, Address A 52 7 "%eso, c 5rreer City r Zip ,3112../ Lic# 50615, Phone# (9)Z6^(-?ezt <br /> Address City Lic# Phone# <br /> ,Township ;.Z Range C t:7" Section // <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />NEW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />II SOIL BORING # <br />[.] WELL # <br />[] *Other <br />COMMENTS: soi/ <br />g DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />To /5. he/cp, $ <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)(HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN 'CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS [I HOSE <br />OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER APPROX. BORING DEPTH El BOLTED TRAFFIC BOX or fl 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 and Regulations, and all applicable California State Laws. <br />Signed x <br /> Title/Company cec7- r r s <br />Date / - -OS— <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: i,505 /1/ Zde4-?--lez-xA? 9lett_ <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />icio/ .5,8 w., 740'1 a.,, /-i--5 sR# 00 YDge. .. , <br />C-57 WC +7-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />TYPE OF WELL <br />MONITORING <br />[] EXTRACTION <br />[] VAPOR <br />[] AIR SPARGE/ <br />I SOIL BORING <br />[] OTHER: <br />Print Name '<NT' eio <br />EHD 29-02-001 <br />6/22/04