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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS ED...4 2... <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 comp lance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 4000 w'r) fl/t/W- <br />Assessors <br />Cross Street rew 6i"2- City 4-yrimy zip -,5-33D Parcel# /7*' <br /> <br />ORIGINAL <br />AL h SITE <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgs ed* <br /> J 2 11: 49 <br />UNIT IV <br />PfiljA <br />Owner e;1* 4127 / r- 0147/1144eiress //Z00 Getx-iiilldp:: City A777"1/ Zip ff310 Phone# <br />PROPERTY , . _ , / <br />C-57 <br />- <br />C-57 Contractor AtaT,4/irt-L7 Afa/dress 5.-SZ 4/42- 421) City Zorn/F./Zip IVS7/LIc# WriPhone# <br />/...fireept) , <br />Address 3/?iZzike; City Go icia*Lic# Phone# 7/i-ifesC/-05/. Consultant / Sub Cntr 5C-e-0/€-- <br />-*/1) <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFOI <br />XNEW WELL /4OR1NGD(cPT, GEDPROBE, HYPPtOPUNCH, HAND-AUGER, OTHER*) <br />(]SOIL BORKG9T / / <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING <br /> HOLLOW STEM DIA. OF BOREHOLE /'U MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />[] EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL B PVC a OTHER: <br />0 VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL /-5—I TREMIE TYPE TO BE USED: 0 AUGERS [] HOSE <br />0 AIR SPARGE/ OZONE )(PUSH POINT (GP or CPT)GROUT SEAL PUMPED: tYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS /144't 4C-041 1/7-- <br />APPROX. BORING DEPTH 75-1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED /1/6 (if YES, list specifications in comment section) <br />COMMENTS: <br />7O7-37'--- <br />[] WELL # <br />(]*Other <br />DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />[] PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />OIL BORING <br />[] OTHER: <br />0 HAND AUGER <br />0 OTHER <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 />County Ordinanc , Rul s and Regulations, and all applicable California State Laws. <br />Signed x J Title/Company ‘,4w7--- if, 040 /17Z_ -Cat( _ <br />Print Name CZ- //S//-- AtA/ny- Date 6-2c1— Y <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />/6 fl.70 Cot-w144-÷ <br />2e1&3 <br />A <br />/5/ z <br />Date <br />Date Issued <br /> Date ^2*-7 0-- <br />e-oP <br />Area <br />9 <br />IS4-12;ze <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ----- INVOICE MIT / SER ST # <br />1356 I .-13 871/ .572#3 Y- CNA 7. 7.- sR# m3e 7-2-1 <br />C-57j WC Ir-WAIVER C-57 Letter of Authorization to sign permit .L.. Enc3errmerti-cfac-0,4 <br />Altirele,c4•03 <br />Date Final Inspection <br />EHD 29-02-001 <br />9/30/2003 <br />