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Area f 9 7 <br />Date f, Fr, i rti-- Final Inspection By 7 Vi Date <br />Date <br />Date Issued 4 C/o6 <br />an 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.orgiehd <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <br />2006 ,t1 ri 3r23 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEJSSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work detsc.d d.',This.appficatiort is rnade in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Hba_l_th,De.paittheyit <br />- WELL Lo c ation'. 2_t Street 1-4 City 56:-3t / <br />Lt24-)s, --L4N e SS ors <br />-IC *Zip /-73/-L - arcel# 1g )I O 3,6 <br />FoRw On ePr E R Tic) . <br />rtt St(041.)(.._- Address l't)tly Zip2-4.Phone# (2' <br />C-57 ContractcCakCk.a.-keiLi Address36:32 are& e_cv--- City '41/1 ipL-1#711:1Dhoneell4=, /k--, <br />Consultant/Sub Cntr Address S57 SIA Mityi„*-1471tc# Phone# +b7/C-7- 6 <br />GIS Coordinates: X Y Township Range Section <br />WV:2K TO BE PERFORMED: <br />WELL! BORING (OPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />fl WELL # <br />*Other <br />COMMENTS: <br />INSTALLATION TYPE <br />AllIOLLOW STEM <br />( If AIR HAMMER/DRIVEN <br />El MUD ROTARY <br />fl PUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes <br />GROUT SPECIFICATIONS ci) <br />APPROX. BORING DEPTH <br />liCONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: (i ee- 004-5‘ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />OVER-BORE DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />O MONITORING <br />a EXTRACTION <br />APOR <br />fl AIR SPARGE/ OZONE <br />a SOIL BORING <br />o OTHER: <br />0 HAND AUGER <br />0 OTHER LIED TRAFFIC BOX or Q STOVE PIPE <br />CONSTRUCTION SPECIFICATIONS -7 t#1.e.IJI <br />DIA. OF BOREHOLE/C\1] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:cK- <br />CASING THICKNESS --4 TYPE OF CASING: a STEEL e,frI'VC 0 OTHER: <br />DEPTH OF GROUT SEAL 335 :1-TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />(NOT • MAXIMUM FREE-FALL DEPTH IS 30') <br />I hereby certify that! have prepared this application and that the work will be done in accordance <br />County Ordinances, ljuies• -nd Regulations, and all applicable CaliforniOtate aws, <br />&ED <br />A-0ak ( 1 C-) <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 303'Z- la,--/a--era-//t-c, <br />with San Joaquin <br />c•—) <br />Signed x . 1, Title/Company <br />Print Name <br /> AL <br />WORK PLAN DATED: 0 (/- 2- loc.) 4 <br />Date 44-1 -6, <br />Application Accepted By <br />Grout Inspection By e=-. , <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: O. {2, 5/1iP /75-F <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3C-.0? J -79 - .-2 -7/ - IN.° 71 <br />me._ 64-A sR# 00 qw?-7 / <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit Encroachment doc