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<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 / CONDITIONS: <br />Final Inspection By <br />Date Issued Area <br />Date <br />Date <br />San Joaquin County <br /> (:)[3 \pNAL <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 ith 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 1(c 2-00 6c...1•A6C-‘4 s+. Cross Street loco Ccsrt e City Le---ioP Lr Zip 5S3...0 Parcel# i rfic- 21 <br />PROPERTY <br />Owner (-0.6 Address 16200 (›.--•tr:ale Si. City L-1-1,,,-zp Zip 2:30 Phone# <br />C-57 Contractor tniet.ZLIc^-c Ck br1 1:1C cl Address 53-0 City aSIT, Lic# <br />Consultant/Sub Cntr.5-tzo , ./0( , Address .1-1-14-:bazc V,* ItX) City cc2=6,_ Lic# <br />GIS Coordinates: X , Y , Township <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) fl DESTRUCTION (choose type below) <br />fl SOIL BORING # <br />fl OVER-BORE. DIAMETER <br />'WWELL # a PRESSURE GROUT <br />*Other <br /> GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , +I <br />S MONITORING WHOLLOW STEM DIA. OF BOREHOLE e 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: -1--. <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS -..ti- 'JO TYPE OF CASING: a STEEL gloVC 0 OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 2: TREMIE TYPE TO BE USED: 0 AUGERS WHOSE <br />0 AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ,../e_......4.- ce,,,, e ". ÷ <br />0 OTHER: fl OTHER APPROX. BORING DEPTH "1 c ' POLTED TRAFFIC BOX or 0 STOVE PIPE <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 />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 544.-c !lc L1. <br />Print Name 1r'\ Date (2- 5 - e)‘-1 <br />DEPARTMENT USE ONLY <br />SITE <br />DEC I PlititibATION <br />ENV1ROViN <br /> <br />UNIT IV <br />PERMITISOV ICC, <br />f 2ZL <br />44.)1. <br />Range <br /> Phone#WA 3P-1 -40:X-3 <br />Phone# Wto) 9 c. -0`10c, <br />Section <br />ACCOUNTING ONLY: ONLY: AID# FAC# _ _____ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE RMIT / SERVICE # <br />ICI i M W <br /><1,- b,6r7._ at (j ."0, sR# 0,0,9 1,,N <br />C-57 V wc -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit 44-"Encreackunent...siQc...— (2, c -