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, Assessors <br />City S.44--hi4 Zip 151.trz. Parcel# r- <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />orr- <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 5 ide Val iC - ti S. Wri ISM 101 Cross Street <br />Owner <br />i crill cL A.L <br />DI: 3 T1M-TV VI Address 3'15 At C 1 'Dm-ad o City ShtkiD VI Zip 95101 Phone# /-1)/) q3-7 -g3Y7 <br />ed eleoCAu Address 83-7 51,41“.4) gel City .,-)1pg-teli Zip /5-/5 6., 2hone# 511/7P C-57 Contractor Aittlet 14 2Lic# <br /> <br />Consultant / Sub Cntr Ad va Pt ft/ 1176( v Address 37 544,-.) Pei City 90-kkel Lic# 60 .177 Phone# <br />GIS Coordinates: X , Y , Township Range <br /> <br />Section <br /> <br />WORK TO BE PERFO • <br />XNEW WELL fOR1NG 1CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />XSOIL BORING # <br />WELL # <br />D -Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U MONITORING HOLLOW STEM DIA. OF BOREHOLE 1.254 a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />U EXTRACTION <br />0 VAPOR <br />fl AIR SPARGEJ OZONE <br />)SOIL BORING <br />0 OTHER: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 1] OTHER: <br />a MUD ROTARY DEPTH OF GROUT SEAL f i4-; ce. TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />XPUSH POINT (GP or S;PT)GROUT SEAL PUMPED: a Yes Itztio,(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />El HAND AUGER GROUT SPECIFICATIONS Pc1-1-1 a VIA <br />J OTHER APPROX. BORING DEPTH 4 fl BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED JO 0 (if YES, list specifications in comment section) <br /> <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 />Signed x Title/Company <br />County Ordinances, Rules and Revulations, and all applicable California State Laws. <br />e 109 i 6 -f Aga cave we s j <br />11'2,Mi_ ,ex - Date t Print Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: g2V 5. /72/ 6- a <br />WORK PLAN DATED: — <br />-met, <br />DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />Date Issued <br />Final Inspection By <br /> <br />0 51 <br />PLETEEtte <br /> <br /> 'WNW <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />I <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />, <br />- - I <br />) INVOICE / I <br />WC ( (4=;t5 Sti 30 3 I a%***". 2—i ., <br />C-57 J, WC V -WAIVER C-57 Letter of Authorization to sign permit En_craachmeric <br /> <br />9/30/02 <br /> <br />4t-Gleg , <br />OK— in 3- I -