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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 />SITE <br />MITIGATION <br />UNIT IV <br /> <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 1146 S' N)tuatio,Assessors <br />Cross Street ‘j(?,./..1e-S0 St.City ,X(DC.-0011 Zip '95./05 Parcel# I SZ/ <br />Q,Lica:Telli lc Address I r WettittSi. City Si-CC-010A zip 1l5WSPhone# -1-1331 <br />C-57 Contractor AkiVil eig/CilViit&Wakatiress SI 3-1 S LA, V City SielkiCiA Zip 11115 Lic# 0 SOirkhone# IV 7-0,01, <br />Consultant / Sub Cntr A(alliej (it Oelliql/Viti."Widress •,'; 1 1761.4) PA City 4e.4-itil Lic# ).86 )-i_2-7 Phone# 41,7- <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />=E. ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />ArSOIL BORING # i 0 OVER-BORE. DIAMETER U WELL # a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />fl MONITORING a HOLLOW STEM DIA. OF BOREHOLE I 1,5E° fl MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />U EXTRACTION <br />a VAPOR <br />a AIR HAMMER/DRIVEN CASING THICKNESS IA A TYPE OF CASING: a STEEL a PVC a OTHER <br />.... U MUD ROTARY DEPTH OF GROUT SEAL tk. ' leg- TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />[I AIR SPARGE/ OZONEXPUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes ,fr-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />.2/SOIL BORING D HAND AUGER GROUT SPECIFICATIONS 'Wet-lewd- tAr- a".. <br />Q OTHER: a OTHER APPROX. BORING DEPTH 1-15' a BOLTED TRAFFIC BOX or [I STOVE PIPE <br />CONDUCTOR CASING PROPOSED ..,"-- (if YES, list specifications in comment section) <br />COMMENTS: A)120{,A- CLAAAII4,4_,k C.1,101AA—A tiO -- kkl, -KIAAA/14,tA A -Z-1---C <br />NOTE: OFFSITE BORINGS REQUIRE= <br />rze_A. <br />SS AGREEMENT OR ENCROACH MENT 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 14.1-JA Title/Company eietta5;41 Advavtud eieP6-Ko ‘14 e4tizti <br />Print Name <br /> <br />CvfeAve_ L Date R. S nog+ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE,7DDFIESS: 11%4 ".; Si fAAD% A)oty,4jac-,, <br />WORK PLAN DATED: a (-I o <br />Date AAA <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# <br />_ <br /> FAc4t Q_SrRe7o,_%3.93(1 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SE INVOICE <br />3 Sol 4scf.00 • l'tli-li (Ak 2HoLf sR# 3,939 <br />PROPER <br />Owner <br />U *Other <br />COMMENTS: <br />Application Accepted By kiNwAe " <br />Grout Inspection By Lk i-tAnAr-o.--- <br />Date Issued <br />Date 4(810Y Final Inspection By <br />Dat <br />24 I :if &4 <br />trIt6101 <br />Area 6, -2,t <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />9/30/02 <br />