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Application Accepted By Date Issued 7" I OY <br />Date -6/1S1C4 Final Inspection By <br />Date <br />Area 1724, <br /> Date e-P/CY <br />titrutn.".0 `Th <br />Grout Inspection By N. I , • - <br />Destruction Inspection By <br />RECEAD <br />APR 26 2004 <br />ENVIRONMENT HEALTH <br />PERIVIIUERVICES <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 />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 4e 2 . 614.1(-41M9 Sr Cross Street 04.F4At T City c-roocrof4 l'-i zip Aff <br />,Assessor ...- ,, <br /> <br /> .,a i,,,... (;) <br />Parcel* is 'AZ ' vf <br />ay Satt-1-441 Address kti- AL fd.A.14.,St city cram-cvil zidar/ Phone* 44% - 12g2' i <br />PROPER <br />Owner <br />C-57 Contractor ^P-ii,,i-er- //j -Slra Address J2) 01,0k_ citypAry1 /414-zip045.Licitc6-(A /ph. # 903 3g°a <br />Consultant / Sub Cntrkaaltb eaatkibriOkidress y37 szipt-v go Cityr6t4-takt Lic# Phone#0009 7/t <br />SITE <br />MITIGATION <br />UNIT IV <br />GIS Coordinates X <br /> <br />, Y , Township <br /> <br />Range <br /> <br />Section <br /> <br />WORK TO BE PERFORMED: <br />p\KEw WELL / BORING <br />4 SOIL BORING # <br />WELL # <br /> <br />EOBROBE, HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br />13 OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br /> <br />f] "Other <br />COMMENTS: <br />GROUT SPECIFICATIONS <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />U MONITORING <br /> U HOLLOW STEM <br />EXTRACTION <br /> O AIR HAMMER/DRIVEN <br />a VAPOR O MUD ROTARY <br />27 <br /> a OTHER <br /> <br />APPROX. BORING DEPTH 2-0(..) 13 BOLTED TRAFFIC BOX or a STOVE PIPE <br />COMMENTS :.4 CPT 56)1- :ede.i.,Auf c- .4-240o I-FIT 6i <br />CONDUCTOR CASIN PROPOSED D <br />614) <br /> (if YES, list specifications in comment section) <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 prepare this application and that the work will be done in accordance with San Joaquin <br />7 County ' an ,ple nd R__ulations, and all applicable California State Laws. <br />„)(____ (____. <br />Signed x z _ Title/Company ''Petat7" au-4)(4S — Aomicia2 akii4litigivittintrAl— <br />Print Name rAiiii-- g. bb 71CAI Date tL1-2 3 -0(71 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ,60 2_ Ce,t, ,...f-vvi..44 _5 t-- • <br />WORK PLAN DATED: / 2_0(:5 2.... <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE2 ( a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS AM <br />DEPTH OF GROUT SEAL <br />13 AIR SPARGEJ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: <br />ROIL BORING a HAND AUGER GROUT SPECIFICATION <br />U OTHER: <br />Yes p No (NOTE: MAXIMUM F <br />PAe-rol-ALP <br />TYPE OF CASING: a STEEL a PVC a OTHER: <br />TREMIE TYPE TO BE USED: )(AUGERS a HOSE <br />EE-FALL DEPTH IS 30') <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY 1 DATE PERMIT! SERVICE REQUEST # INVOICE <br />3 5-0 i 4 sci . 0 0 a 0 is5 5- it.0 4/2_i../„y sR# s 77 7_6 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encrent_cloc 9/30/02 <br />Si7NO <br />