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San Joaquin County <br />Environmental Health Department RE EN,/ , oTE <br /> <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd AUG 30 2 004UNIT 11/ <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENVIRONMEN I ditALM <br />P <br />Health <br /> R <br />Department. <br /> M l TSi sE R e n C iE S <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application m compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental <br />Assessors <br />WELL Location 4441t Palyldt. AtXtrtae.. Cross StreetRiAematio in_ City 5Lciftm.- Zip 95209 Parcel# <br />PROPERTY <br />Owners-41%4 T fd E-7rissiy LP Address g7-t) FiAtteide-co Staset-City5agattgA;Aagip14, /13 Phone# <br />C-57 Contractor (ii_sikti,464_, Address City Zip (Til#1 17 Ci Phone# <br />Consultant / Sub CntrE77C ,itj,Z042toatig Add ress11/151/01R.L AVQ.Cityllethdallitic# Phone#T,LS.- 602-470 <br />GIS Coordinates: X V Township 2/Y Range 6E. Section <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />U SOIL BORING # <br />XWELL # Alt _Spat" a *Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS " ..--.. <br />0 MONITORING XHOLLOW STEM DIA. OF BOREHOLE g" XMULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:j-'- -41;z1 <br />1:1 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: „littTEEL 1:1 PVC ['OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS XIOSE t <br />XAIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: XYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Neat cii-Meittece-t- <br />0 OTHER: a OTHER APPROX. BORING DEPTH X <br />Br <br />TED TRAFFIC BOX or g STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (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 and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules a1 R ulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name A.164-,-- L C. i - ce--- 5 0 , Date 2 VZ 670 't <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issued (infri/t)t/ <br />Grout Inspection By /.*"...-o-e-t Date q12 i/D Final Inspection By <br />Destruction Inspection By Date <br />Application Accepted By aktA-A-E-- "( Area 1712 7 <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />—, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE : E REQUEST INVOICE <br />7 tr? Auc_ 7//1/ , SR# z,e7394 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001 <br />6/22/04