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Cross Street City Zip 15(01S 49 Parcel# (ft) '-'la- 7-0 <br />Assessors <br />Date Issued <br />Date <br />Date <br /> <br />Final Inspection By, <br /> <br />ORIGINAL <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 /> <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 />WELL Location ?Ail- 01) ige /LA <br />pec,4 Vs; <br />PROPERTY <br />Owner Liolveys-Al Fo Keg Address .2"42 C..- • c-b1+1 "1 14E-0-ity CI ifki".1 r-oriszip 441c1-S-Phone# Gf I 14- t t <br />C-57 Contractor vicLwvI dy; 11 ; ri Address r.o.gc -A 37 City (2- ID Vic40Izip CP457 Lic# /10011 Phone* 1 - 4- Li- 7>c,--77 <br /> <br />Address r. 0. g 0 gq Lic#CC3q/01- Phone# Cl 0 -‘9 Consultant / Sub Cntr C <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />giNEW Wp_L I BORING tcyl, GEOPROBE HYDROPUNCH, HAND-AUGER 0 <br />4SOIL BORING # I 11,-S <br />0 WELL # <br />1-0 o *Other <br />COMMENTS: Enrvivi si /ft v-a p vtele) I (eill 1/i _s <br />ER*) DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />°t3 Vji i i c-x-i-c4,1 4-v cl r-1) -111 — to. 6A..s <br />0 <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U HOLLOW STEM DIA. OF BOREHOLE 1.--" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <Z) <br />AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br />0 MUD ROTAR DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />Q/PUSH POIN r CPT)GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUG GROUT SPECIFICATIONS <br /> 0 OTHER APPROX. BORING DEPTH 1.0 0 BOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED <br /> <br />(if YES, list specifications in comment section) <br /> <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 Ordi ances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company pviric.ro I / C. <br />Date 1- ° <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2,--6 4(/ .711-ietA4/11t <br />WORK PLAN DATED: <br />TYPE OF WELL <br />J MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />2/SOIL BORING <br />U OTHER: <br />Print Name <br />5 Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAG,* <br />-, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DAT PERMIT! SERVICE REQUEST # - INVOICE <br />35‘b <br />Air. <br />Air 0 .' S-7--ZO <br />eiAA SI, 00 VI /5 ..X <br />C-57 V WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit i-Trear_b_rnent doc <br />EHD 29-02-001 <br />6/22/04