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EN VIRON114,. <br />PERMIT/L(.iviCFS <br />- SITE <br />OCT . lylITIPATION <br />tfriciif <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 />COMMENTS / CONDITION <br />Date Issued <br />Final Inspection By Date <br />ate <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <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 10%6 6 64,4, 11 Cross Street COIli <br />Assessors <br />City A etlievieD Zip 1 74 4-1-/ Parcel# cv5 -1,1 3 z.. <br />ddress ,1-41 e ,,k, rai City a,..,..ti, zli z al photo 3G4- /II e) t f A)y..74. .... <br />C-57 Contractor Address 444-1447e504 1- F-4- lac 4 -(64.,141 Zipaiaptrit41:51/"Zhone#01175) 3/3 -1*W 41(76/ <br />Consultant / Sub Cntr Address g..4' 7 ,4034....; 4,01 City .5e'4--1:71-Lio# 6f3t IL 27 Phone# <br />GIS Coordinates: X , Y Township L/A/ Range if E Section <br />PROPEL Y <br />Owner <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING <br />WELL # <br />SOIL BORING # <br />EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />LI OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />*Other <br />COMMENTS: <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />El HOLLOW STEM <br />DIA. OF BOREHOLE PI a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING Dlk <br />fl AIR HAMMER/DRIVEN <br />U MUD ROTARY <br /> CASING THICKNESS TYPE OF CASING: a STEEL a PVC U OTHER: <br />DEPTH OF GROUT SEAL (:)/ TREMIE TYPE TO BE USED: AUGERS U HOSE <br />)(PUSH POINT (GP o GROUT SEAL PUMPED: ,:frYes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U HAND AUGER <br />GROUT SPECIFICATIONS i>cf•i4a/kA T-Er <br />APPROX. BORING DEPTH to)Of 1:1 BOLTED TRAFFIC BOX or a STOVE PIPE I] 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 and that the work will be done in accordance with San Joaquin <br />Cou rdinances, ules and Regulations, and all applicable California State Laws. <br />Signed x /WA--- Title/Company Rarkr5-6.Ebtit)e)r-..<1— <br />Print Name ! / kOt is. a C 1^% Date 9/o /e51 <br />DEPARTMENT USE ONLY <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />fl MONITORING <br />EXTRACTION <br />fl VAPOR <br />U AIR SPARGEJ OZONE <br />)(SOIL BORING <br />OTHER: <br />ACCOUNTING ONLY: AID#LI FAC# 04- kit"; ilem. Nryfir <br />INVOICE PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D B - r , , ERVICE REQUEST # <br />.00 zego 1 4i'54 D o3 ?ei a 7 ; <br />C-57 WC -WAIVER C-57 Letter of Auth to sign ermit E <br /> <br />EHD 29-02-001 <br />6/22/04 <br />