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San Joaquin County <br /> <br /> <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: vvww.sjgov.orgiehd UNIT IV <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 with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />Parcel* 23-0--/76 /2- WELL Location-242 W 'TOOLE( -R-OOC) Cross Street 111VCity Zip 9324-2 <br />)n 0 1\4' a_tito LA) • Tufidt-A-N., <br />Owner k, <br />PROPER <br />Address Mir/-07 441.5644-44 City heti zi17-524, Phone# (217)369 -37 7 / <br />C-57 Contractor(tiSeckALDO Ottlitiott._ Address 3(232-0W.QQ Ci rat_ City C..01A-CAut Zip(151/1ZLic# 311si VPhonek99 63 E3- i/6 <br />Consultant / Sub CntrACIVOLJ-CeC) Address e77 Sinaki361-Z citleKre Lic# 6.g 02 23 phone#(24467-/Db <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />rEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br />1:1 SOIL BORING # a OVER-BORE. DIAMETER <br />ELL # a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />11:1'N'Other <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / // AONITORING XHOLLOW STEM DIA. OF BOREHOLE Sir 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS O TYPE OF CASING: a STEEL XPVC a OTHER: <br />U VAPOR 1:1 MUD ROTARY DEPTH OF GROUT SEALIM /2 D e TREMIE TYPE TO BE USED: .WAUGERS 0 HOSE <br />U AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED:)Pes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS yo,i6=4,ey 91ca i-r, =,,,te. fix,C) <br />U OTHER: a OTHER APPROX. BORING DEPTH /1?,0 424.- V3OLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED Al 0 (if YES, list specifications in comment section) <br />COMMENTS: c4/6(4' <eteez.f t di to Woo' /20 - /26 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 14L---- Title/Company Nyil t-i mi3O (-e,0 <br />Print Name 'b'Cl VI le1 ValikkL\ Date S4 <br />DEPARTMENT USE USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By /..1 1A/L.0-e Date y()_slc_, Final Inspection By <br />Destruction Inspection By <br />Area /17 <br />Date <br />Date <br />COMMENTS! CONDITIONS: ct?..e_o LiJk-e-A. (7 14 IA-15 -L 0 r <br />ACCOUNTING ONLY: <br />r <br />AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM- IT / SERVICE T # INVOICE <br />3 SC/ 6'i'-' ' 8-5 '' z 2 _ 6 */ 8) 1,4e____ Oa.) SR# 0 0 I. 1 / ? ? E. <br />C-57 <br /> <br />WC -WAIVER <br /> C-57 Letter of Authorization to sign permit En <br />EHD 29-02-001 <br />6/22/04