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Signed x <br />Print Name xAc <br />Title/company o J' .17417,- <br /> Date <br />San Joaquin County <br />REG IT Avenue, <br />Health Department <br />venue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Fr 15 70E. well Permit Application <br />ENVIROMEA; L4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6-te <br />Application is hereby made to UrC11814AM 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 />Msessors <br />Cross Street Wet', ild'E City f We'4-17'11' Zip r I 2 / 2 Parcel# <br />(4-16 eI9 (4.--r -4 <br />fiwel-44/ Zip 93725 Phone# 4''V17/4-- 2#'e' <br />Address 11,17 ka 64:zee-RA City e•-•-•COes-"I' Lic# 75-4'54 Phone# 0,s0 ..c•W Consultant / Sub Cntr e'4° T <br />GIS Coordinates: X , Y Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />SOIL BORING # <br />O WELL # <br />*Other <br />COMMENTS: .111i41- r"e Wee <br />'B DESTRUCTION (choose type below) <br />AOVER-BORE. DIAMETER 7" <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />WELL Location 7fre APIN Pilaf/9' /7 <br />PROPERTY i.4(4' x"1414i/11//'" <br />Owner (se <br />, <br />/4't Afirte.Pra--5) Address .5 V13 e,64-419A-Fe LA/ City <br />C-57 Contractor We 6-00,69 /70 *WegfAddress grin, eedlifirt ,f0/11) fie City 7/2469.4,1 69Zip Lic# 2173.-Pe Phone# ir7f-30 ?Ls' <br />re, /OP /por„freme, <br />INSTALLATION TYPE <br />,ITHoLLoyv STEM i-1,. <br />fl AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />OZONE 1:1 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: <br />0 HAND AUGER <br />11 OTHER <br />TYPE OF WELL <br />(IIMONITORING <br />0 EXTRACTION <br />O VAPOR <br />U AIR SPARGE/ <br />0 SOIL BORING <br />fl OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE fi MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: U STEEL a PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />U Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS ..ez-", <br />APPROX. BORING DEPTH <br />-,4vE.477- <br /> BOLTED TRAFFIC BOX or a STOVE PIPE <br />COMMENTS: r-c wn-e. al/Li <br />CONDUCTOR CASING PROPOSED <br /> <br />(if YES, list specifications in comment section) <br /> <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 />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (.1 ci <br />WORK PLAN DATED: "Tr (c ( rn <br />Application Accepted By !,4>vinet <br />Grout Inspection By 1-4>4.4AA.nr <br />Destruction Inspection By <br />Date Issued <br />Date "2, (; e, 4i- Final Inspection By <br />Date <br />Area , <br />Date <br />- <br />Date 3 <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: A1D# FAC# c <br />-, <br />5-RD9413Ceo <br />PE CODES FEE INFO ' AMOUNT REMITTED CHECK # REC'D BY DATE PER INVOICE <br />3 co z_ lis 6,0 , 0 c.) 6 0 s-`tEs a .zizcic,- SR# ti I ,LO <br />C-57 <br /> <br />WC -WAIVER C-57 Letter of Author'zation to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04