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I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Otdijances, Rules and Regulati s, and all applicable California Stat. ws. 60 <br />j&A <br />Date <br />Title/Company Signed x <br />Print Name_LPYWN <br />eDt <br />1,1 13 — 0'1 <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />UNIT IV <br />04 NOV 12 PM ir 43 <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 11201 TIAMPN-12, V0( 4)14 Cross Street <br /> <br />Address ft. o,,60,1( (0 CO City SiZCV-frA Zip 9Q06phone# (i(o) 3(o —0( 7 3 <br />C-57 Contractor <br /> <br /> Address toot-3 1flici_24 cityislatatkiik-"+ic#6701W -Thone#91,-6,3/-3Si3 <br />'3-37 SVvx.A.A) Cityan_Lic# ef XV7phorie#: Consultant / Sub Cntr (5) Address <br />City ).-a./i<1.311 Zip952101 <br />Apsasrce(sls#o ristos....0/0 /3 <br />PROPE T <br />Owner <br />GIS Coordinates: X <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />)( NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (choose type below) LI SOIL BORING # <br />0 WELL # 3 0 PRESSURE GROUT <br />fl *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />!(,MONITORING %HOLLOW STEM DIA. OF BOREHOLEIPSla MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: cZ/1 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ,VC 0 OTHER: <br />0 VAPOR 0 Mt . ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: UGERS a HOSE <br />fl AIR SPARGE/ OZONE 0 PU....1 POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes gNo (NOTE: MAXIIVIU FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS fo rticunci <br />011495.5 OLTE 0 OTHER: a OTHER APPROX. BORING DEPTH 3 TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED i\JO (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 />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 16 0 1 Turri jo;ke, `Roaal <br />WORK PLAN DATED: klu,st 21.I 2004' <br />Application Accepted Byc Viejo r L MC-ear -be-lel Date Issued vembe,rI t I zoo4 <br />Grout Inspection By *2,4• ck<VAidtit,67 Date - -2 Final Inspection B 402.44 t ik(44/.,CiitDate <br />Destruction Inspection By I Date <br />Area 4 5 9 <br />/(-- 22- -0 <br /> <br />COMMENTS / CONDITIONS: .5 fa)L&+:O71 cif -th re e, to nd Y1 140 Y .ij wells iM W - Ir2,- 3 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />— <br />PERMIT I SERVICE REQUEST # NVOICE <br />35- 0 1 <br />/* <br />g 9. 6 0 <br /># Sq. 00 SRiV------ 00 <br />------__,,,\ <br />/ 403'7 I <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />'Encroachment doc <br />0 OVER-BORE DIAMETER <br />EHD 29-02-001 <br />6/22/04