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'7- Date Final Inspection By C Date 4-44-44 Date Issued 6 —//— 2—tormArea Application Accepted By Grout Inspection By Destruction Inspection By COMMENTS / CONDITIONS: WELL PERMIT APPLICATION FORM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 304 E. Weber, Third Floor, Stockton, CA., 95202 (209) 468-3449 ORIGINAL SITE MITIGATION UNIT IV oFE v (Ai A NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin county Environmental Health Department. Q a j C. rAciFic Ave Assessor's WELL Location i -,( / ---) PAC/Fit, AV elePe,Cross Street a; 4,.,,.. ki Sr. City STOCK TOr) Zip 9 52 p 7 Parcel# //o- ZY0 - )5 ct c:A; , PROPERTY Owner #11‘Ch4:1 t I 111u/1455C i'' Ct Address rat 149a 6 ' H481" City e- L p 0 I Zip '150 2-Phone# 2'3(08- <V '7k r7.iii El' W a C-57 Contractor " 51. f A TA Edit (IA/ welAddress Pt C. B,,, 1 to A City sikrA4nr'Zia95 " I Lia#512 //q5Phone# cf ib' 3 73/4 Consultant / Sub Contractor n . (1, • ci • Address 3'37 SNAva no City S-Trk('f,"Lic;# (A (:1Z 77PhonetA20) Yg 7 -1 on GIS Coordinates: X Y ,Township ft,i Range If) E---- Section 5 WORK TO BE PERFORMED: IcNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) 0 SOIL BORING # l] OVER-BORE XWELL # thAi-i,vvi-Z-,Aiw-I ) r: t--i 0 PRESSURE GROUT *Other: Grout Specifications: Pc, LT 14 ,.. 0 Tv, f - 12C-- f — COMMENTS: S ri ft A Pp. (.4,Q.D vvo tic. Pin,/ DA -r...o I 5 F-F,FIN•Gi -1 0 c - TYPE TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 MONITORING 'HOLLOW STEM DIA. OF BOREHOLEb 4-/ 43 11 MULTIPLE CASINGS? a YES KO WELL CASING DIA:2"- " 'EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS (.‘11, go' TYPE OF CASING: a STEEL KPVC U OTHER: VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5 ...f 45(.. TREMIE TYPE TO BE USED: )(AUGERS a HOSE XAIR SPARGE a PUSH POINT GROUT SEAL PUMPED: il Yes r 0 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: Pr 1,'o •TypG. .71 0 OTHER: 11 OTHER APPROX. BORING DEPTH 96 FT, 8 SC 34130LTED TRAFFIC BOX or 0 STOVE PIPE CONDUCTOR CASING PROPOSED? pj c, ( if YES, list specifications here): *COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California State Laws. Title/Company Ppc,;..,L f EA Sisi i9 = 6 • E - Signed x it, e%...1 Wis..— I j . Print Name / l'ivir,7711 v.; (vttlk."-- Date Si 2 V411 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE, ADDRESS: 4 5 RI- WORK PLAN DATED: 2 1'5 • 0 2— ACCOUNTING ONLY: AID# FAC# -- PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQi T # INVOICE /66756f:14 t ? CSR# OD .ocyri 2_ C-57_Li WC /-WAIVER C-57 Letter of Authorization to sign permitV ---1-(25/02 Ave-44.> arata4.)144.4a