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Final Inspectio Date <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date lssu <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <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 />GrIN A 1_ <br />DEC 1 0 aft <br />ENVIRL MITIGATION <br />PERMI T UNIT IV <br />ce314t <br />ME <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 />c_ Assessors 1 (51-1- <br />City Leq'S Zip 5-330 Parcel# enc- cael WELL Location /(LII(Le t Cross Street <br />PROPERTY <br />Owner ct;c Lc414-,00 Address 167-7--c S. 1lcJ rA City 11-1 trap Zip S--3;) Phone#(20(?) V-1•9 <br />C-57 Contractor 141,01.,.14-ct t"'• r)C,-.• Address 33-0 12,1 , (...)Vc-, Zip cit i Lic# i/OC• -14-c Phone# (7e) 4 3co. <br />, <br />Consultant/Sub Cntr 6e-cos- :Cot, Address 3.17- /4.:Nort.. i2rtigr/4tity etoLA. Lic# Phone# ("1/(:))i,k;/ <br />GIS Coordinates: X , Y Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />&NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0:SOIL BORING # <br />trWELL # <br />fl *Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />D OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />INSTALLATION TYPE <br />WHOLLOW STEM,11,11e,11\) <br />fl AIR HAMMER/DRIVEN <br />O MUD ROTARY <br />TYPE OF WELL <br />RMONITORING <br />El EXTRACTION <br />0 VAPOR <br />fl AIR SPARGE/ OZONE <br />II-SOIL BORING <br />0 OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE P, a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2-a <br />CASING THICKNESS L- Li TYPE OF CASING: a STEEL WPVC a OTHER: <br />DEPTH OF GROUT SEAL 2 TREMIE TYPE TO BE USED: a AUGERS WHOSE <br />a Yes it-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />tt/e,+ <br />' FOOLTED TRAFFIC BOX or a STOVE PIPE <br /> (if YES, list specifications in comment section) <br />' () • , 11 • •- t • <br />ByusH POINT (9E or RPT)GROUT SEAL PUMPED: <br />HAND AUGER r- GROUT SPECIFICATIONS <br />D OTHER APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED <br />sr),:•--.1)f (---- <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 Ordinan es, Rules and Regulations, and all applicable California State Laws. <br />Signed x ("e‘. -.,44----- <br />e•-• • <br />Title/Company Stt.cf- ,DC. P%-"14 ;-.2/- /,`::4 &C.- 0 t IL r, f. <br />Print Name /1/4.- 4-(—c,...) ,._. 4 L' i \ Date /7- q --c"-1 • <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY INVOICE <br />) <br />DATE <br />IVkf <br />PERMIT! EST # <br />SR# CoY6q32--.--- Gx,f( <br />EHD 29-02-001 <br />6/22/04 <br />-WAIVER C-57 Letter of Authorization to sign per