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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: vv-ww.sjgov.org/ehd <br />Well Permit Application <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 />Assessors <br />WELL Location ,2491) IN, Tot ,,,.0 g._ k. Cross Street RAP teciy... DE. City t.oct i Zip Parcel# 029 -170 -12. <br />/, .5a City fdi Zip rye fif gel e <br />PROPERTY ine.--.01 /3 A 0.S., <br />95 Address/09 0 242 Phone#POP Cri -37 7/ <br />C-57 Contractor/6'44g //IA ki3 EA i Address -NO0Myrfie A-ve cityFoielA zip9C5o3Lic# 6736 /7Phone#(707)441 -9040 <br />Consultant / Sub Cntr Min AcStrVle-cEnt /, Address i337 shclw lad citkifrodfilauc#6go,227 Phone "10 ( 0 ac, <br />, Y Township Range Section GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING <br />[I SOIL BORING # <br />X,WELL # "3 <br />a Other <br />COMMENTS: --/-A t•-e 114.011 ; 1Dr/ 5, Lop '1t) cirp ft, s <br />ct. (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />) Sot, (.2„) ?o <br />TYPE OF WELL <br />*MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />1:1 AIR SPARGEJ OZONE <br />SOIL BORING <br />O OTHER: <br />COMMENTS. <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / XHOLLOW STEM DIA. OF BOREHOLE B" MULTIPLE CASINGS I] MULTI-LEVEL WELL CASING DIA: G. fl AIR HAMMER/DRIVEN CASING THICKNESS _._,VNAAD TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />MUD ROTARY DEPTH OF GROUT SEAL 30 /-1-v 120 / TREMIE TYPE TO BE USED: 7AUGERS 0 HOSE <br />PUSH POINT (GP or CPT)GROUT SEAL PUMPED: OSYes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS pod/cued etio...etli <br />0 OTHER APPROX. BORING DEPTH 6IYand [I BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED A/c) (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 prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signedx I Q..—Q Title/Company ICS) S-1 / AdUZUCd ee.)6/01/CY1/(e/A‘ <br />Print Name -.)(Irl 9Wet VA to Date A2/7/2 190ei- <br />DEPA RTM E NT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By, <br />Grout Inspection By If <br />Destruction Inspection By <br /> <br />Date Issued <br />Date I I-3o it c Final Inspection By <br />Date <br /> <br />/ 2 4 /,' <br /> <br />Area 97 <br /> <br />A.A..o4 I <br /> <br />Date <br /> <br />COMMENTS! CONDITIONS 1-,0 P <br /> : Artig <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE F,BMIT-4-&ERVICE.ft ST # INVOICE <br />-7.4ç43-0 ,i,..e._ , z./,(4, i sR# <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit EncroaChment doc <br /> <br />END 29-02-001 <br />6/22/04