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WELL r'ERIVIIT APPLICATION FuM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />2 8 7005 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALI (209) 468-3449 <br />PET.MIT/SERVICES 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 51 51 mw,,68 1)v Cross Street Otecander City AA04 4 11<-4‘ Zip 9 5331 Parcel# V4 3 "130 - 13 <br />PROPERTY Owner liv; W.c4--N Hot 'r > Address 5151 Atlev,0"ci txiood Dr. City M ced\ Zip 1531 Phone# -Z 0 9 <br />C-57 Contractor EAnv ir.k Address 51AcAr P icAce- City Vallei Sr 4i/zip I 5252.- Lic# toff 3317 5 Phone* zog - 35 74, <br />Consultant/Sub Contractor treo 1e.eo h.s.:47 <:S Address '1I '-I AAc‘z.- 5+. City ES (4 Lic# Phone# 704--7r es <br />GIS Coordinates: X Y Township -2. 5 Range 7 E Section l &- <br />WORK TO BE PERFORMED: <br />,NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />g SOIL BORING # c?-1- <br />ff.WELL "AtAit, AAW`1, AA.,^)1 °, AA WI <br /> Grout Specifications: <br />SITE <br />MITIGATION <br />UNIT IV ruI <br /> <br />Wir <br />*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type teiow) <br />0 OVER-BORE <br />0 PRESSURE C.'3RCUT <br />TYPE OF WELL INSTALLATION TYPE <br />FMONITORING g HOLLOW STEM <br />E EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SP'.ARGE POINT <br />fASOIL BORING 0 HAND AUGER <br />fl OTHER: U OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 5"/ MULTIPLE CASINGS? 0 YES U NO WELL CASING DA: 2" <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 15 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL Z. S FP. /2 ‘FhTREMIE TYPE TO BE USED: ,AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: .&J14- yon-de eve.' <br />APPROX. BORING DEPTH \9 E+ 140 P+- liBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 />S,oned x Title/Company <br />Frint Name jjAh.,"- Date (nr-S--/I /OS <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: tillo <br />Application Accepted By <br />G.-out Inspection By <br />Ciz:ruc:ion 1.,:ion By <br /> <br />(A <br />LA <br /> <br />Date Issued <br />Date 3( c`( (0 )- Final Inspection By (As?rtnAn owes^. <br />Date <br /> <br />Area <br /> <br />Date 3 it SioS <br /> <br />DEPARTMENT USE ONLY <br />TC.'.17.1ENT3 CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC:-' <br />I <br />7 E CC_'.C.'.:ES 1 FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE p: I' - '. REQUEST # INVOICE <br />“-0 1 IM,00 (7 fq740 /te 5 /6'WilIMIESSIMkk .: V <br />C-57 Letter of Authorization to sign per Encroachment do 1/25/02 (2-57 2_-WAIVER