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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application ORIGgAvt- <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 />WELL Location i3Y9 tJ . i`a,� 5 F,ee N�✓�{� �f Assessors <br />Cross Street t City Zip 2'5-3>C' Parcel# 21633034 <br />PROPERTY <br />Owner_ It �.KorPora{� Address P.O. pox -)Il City24a5 Zip75 Zzl Phone# <br />C-57 Contractor G ✓e Dr'*, 9 ,A —I <br />� 1 Address �4n T Gerr i.3 floe City t�;�1 Zi �,�go� r ;-, "c <br />p Lic# Phone# S& a- ya 7- 689y <br />Consultant/ Sub Cntr566Dk rK+e tai asi Address3O17 µ� fta.�ai-o <br />Kilfo'e City rdouw CoLic# Phone#9/G-S'6f-OYoo <br />GIS Coordinates: X Y <br />Township Range 9 Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, <br />SOIL <br />HYDROPUNCH, HAND-AUGE , O� p DESTRUCTION (choose type below) <br />_ <br />a BORING # <br />KWELL #_ - <br />0 OVER -BORE. DIAMETER <br />, <br />j,'Other0 <br />PRESSURE UT <br />O <br />24, -0'4 <br />GROUT SPECIFICATIONS <br />COMMENTS:—.O r f1s� <br />TYPE OF WELLS INSTALLATION TYPE <br />MONITORING <br />CONSTRUCTION SPECIFICATIONS <br />13 HOLLOW STEM <br />DIA. OF BOREHOLE Q„ Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />� EXTRACTION Q AIR HAMMERIDRIVEN <br />VAPOR <br />CASING THICKNESS> 4eJ- Sa TYPE�OF CAJLN�: O STEEL � PVC Q OTHER: <br />V� <br />0 0 MUD ROTARY <br />DEPTH OF GROUT SEAL3y ana( 1? �EMI++E�TYPE TO BE USED: <br />� <br />BAUGERS 0 HOSE <br />Q Atli SPARGE! OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: es , <br />�N p No (NOTE: MAXIMUM FREE -PALL DEPTH IS 30 ) <br />SOIL BORING a HAND AUGER <br />GROUT SPECIFICATIONS New.{- Ce ­ <br />0 OTHER: fl OTHER <br />APPROX. BORING DEPTH YO "&jj aS, L� B LED 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 and Regulations, and all applicable California State Laws. <br />SignedxT �.+.-�^�,�� Title/Company Pecf- (ne.01o4;St <br />Print Name 0. o A row,,. _ Date_ 61-L 810 6 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />C-57_ WC= WAIVER_ <br />EHD 29-02-001 <br />6/22/04 <br />Date Issued J U I Z0 U L Area 145-9 <br />T� <br />1 Inspection By V i C iUYo4' MdC4r'I ,Date Ll- 24.0G <br />C-57 Letter of Authorization to sign permit €ncrouchment-dee-----' <br />mt.19"bb <br />