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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 />Assessors <br />WELL Location 5q00 11/447.40VIX ?_41 Cross Street ChkaP€ <br />Irff <br />City („1--o_40 A Zip tii5t EP--) Parcel# <br />PROPERTY <br />Owner MC;Oft 111,1,Cr-- LOS Address pD 'Box 8-3u 7 City St-tAti Zip C16.2Dg Phone# 41; -3101 <br />C-57 Contractor (4 fetTii ciil):144-Address C150 1-6,0t. City fAmiikoZZiP <br />So <br />Lic-itoori-ttPhone# /5) 3r-6-60) <br />:1 Consultant/Sub Cntr I Va totted, Cleoenu. Address 8;1 skttu) a City (S4-04.4DhLic# n Phone# qb 7 " /COG <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />)(NEW WELL / BORING (Cr, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") a DESTRUCTION (choose type below) <br />' 'SOIL BORING # a OVER-BORE. DIAMETER <br />'D'WELL # a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U HOLLOW STEM DIA. OF BOREHOLE -2." a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />a VAPOR U MUD ROTARY <br />EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL I] PVC a OTHER: <br />DEPTH OF GROUT SEAL -111)10 TREMIE TYPE TO BE USED: a AUGERS XHOSE <br />AIR SPARGE/ OZONE XPUSH POINT (GP o GROUT SEAL PUMPED: 2,es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS c'+ 4t1 aija XSOIL BORING a HAND AUGER <br />APPROX. BORING DEPTH 100 a BOLTED TRAFFIC BOX or a STOVE PIPE OTHER: a OTHER <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 acid 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 <br />at r A <br />Title/Company <br /> Q ,N.kTi t.1141 Acie, aut._ tut <br />Print Name ('VA{... Dad V3 3- V3--o4 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3400 gew4-6,N.. —go"( <br />WORK PLAN DATED: deblUtirt., 2J 2o44 <br />Application Accepted By V; c.kor; A._ Me dar + az/ <br />Grout Inspection By Vie.tbr:ek. Aitea rfrose, Date it/ 7/ ts <br />Destruction Inspection By Date <br />,) 1 , <br />Final Inspection By V:Cki. fl1e4 k-ht-gt Date - 7 -0 <br /> <br />Date Issued Mdi re.11 24, zoo + Area 145-9 <br />COMMENTS / CONDITIONS: Ad vati•ege",erti. 0 f" Orig. PT ; ri& and CM 4Ce/rik..540, ))04 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PEH__3_L__/vin' SERV INVOICE <br />3 So 1 Oct 00 gg, b 0 ( SR# 00 3 7 3 /q <br />TYPE OF WELL <br />fl MONITORING <br />*Other <br />COMMENTS: <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ncro ent d 9/30/02 <br />