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GIS Coordinates: X , Township Range Section <br />FACt ACCOUNTING ONLY: AID# <br />an Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202;3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgiehd <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 />PROPERTY <br />Dr, e" „ Cit73 <br />Owner /60.etie-Zddress City " <br />iL <br />-tone# <br />C-57 Contractor_ _c A , iess 't n k/C:-( City 3A C— Igc# 51bh:bne# /11t <br />Consultant/ Sub Cntr Address r' 1:2(..dty 37 "Phone# 7 <br />WORK TO BE PERFORMED: <br />IEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, °THEW) a DESTRUCTION (choose type below) <br />a SOIL BORING # <br />a WELL # <br />fl *Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 Piz- <br />010NITORING /0"4DLLOW STEM DIA. OF BOREHOLEFt ift liAMULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: ....,, _ <br />... ., <br />U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS , ,. TYPE OF CASING: g STEEL "1:1,PVC g OTHER: <br />U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I 41) rer±TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />U AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED:„11`Yes a No (NOT: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: n OTHER APPROX. BORING DEPTH /6-.. f.: j].,BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 an Regulations, and all applicable California State Laws. <br />Title/Company 7 F <br />SITE MAP IN UNIT IV FILE, ADDRESS: IR•=-1 — Si,te <br />WORK PLAN DATED: -27 rti, 2O'7 <br />Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br /> Date .07 Final Inspection By <br />Date <br />Lpf L,(Lif Li)03724.1a,' <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />3SoiitcJ <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EI-ID 29-02-001 web <br />6/22/04 <br />ecoi sR# 00c-is"; <br />Date <br />Cr5?.05ssessors <br />WELL Location • 0 t Cross StreetOril.016.--11„City iL- Piti-A Zip Parcel# <br />fi OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />Signed x /eiv <br />Print Name kV/ AO 1 till.0 Date <br />DEPARTMENT USE ONLY <br />Area Tr Date Issued 007 <br />SITE <br />MITIGATION <br />UNIT IV