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Date Issued <br />Final Inspection B <br />/1.-- 9 -3 Area <br /> k‹z Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Date <br />Date <br />'RECE VEIL) WELL PERMIT APPLICATION FORM (2,TGINAL <br />NOV 2 4 2003 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (209) 468-3449 <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 ?too (4444-11-7 (- 6( / Cross Street /erg k <br />/ <br />c- City Zip 175.2e Lt Parcel# <br />., Assessors <br />MITIGATION <br />UNIT IV <br />ON' USD <br />PROPERTY Owner pit - 1)-c to Address 1°)4.:)<- 330 <br />C-57 Contractor V ECU Address 6706c/ <br />Consultant / Sul;) Cntr tyti Address /3U1C <br /> <br />City fr-tka 6.7, Zip ?5-2,3 (Phone# 912 - 0'1 27 <br /> <br />City 1..5 itI7N-- Zip q4-5-/Lic#71CgCY Phone# -1174/ <br /> City $774 frk LicJ75 Phone# zof -77 2 .362i) <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPU CH, HAND-AUGER OTHER*) <br />ID <br />AidGve I " <br />0 DESTRUCTION (choose type below) <br />fl OVER-BORE DIAMETER I XetiS <br />fl PRESSURE GROUT j <br />GROUT SPECIFICATIONS /7 armdz.-'n <br />0 SOIL BORING # <br />fl WELL # <br />*Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />B MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -t--/' TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS A/C74-7- <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 1/ ,,-/O--- /7 at„c,m___ Title/Company /2Ic-i) ,IJI- ( 7/4.1-•&-f, 4 <br />Print Name 1i Cr 13 CV E-P1,11- ' Date /7 /2-//t --1, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: //—Z-• <br />20537 act43 4.0147 <br />DIA. OF BOREHOLE - 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE - I/ _ - - - al.,.., # INVOICE <br />35c-: 3<. \A],b 6 b,— 1'frst! it /2,q. (sR# a 3 6 5/? rAm <br />C-57 WC V -WAIVER 9/30/02 C-57 Letter of Authorization to sign permit roachment d