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Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ligIFEUTSERV <br />ENVIRONMENT HEALTH 0#: i \AW 22 <br /> phone# (M) ,65(b.- 12224 <br />Zip (45141)-Liciii?T -It, Phone# (4 ite)tiV ii v - <br />Phone# ((e) Q t- OLIC <br />ORIGINAL San Joaquin County <br />Environmental Health DepartmWC vED-) SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sigovAmong 2 1005 UNIT IV <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 />210- 02 Parcel# <br />PROPER' <br />Owner_ Owner_ /4 <br />C-57 Contractor <br />Consultant/Sub Cntr Address3D1-1- fCite-K-'d 10 <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />COMMENTS:f(t 1,61 2L, insi-(10 <br />01 NEW WELL / BORING (CPT, GEOPROBE <br />' 1:1 *Other <br />,g WELL # '2-2- 0 SOIL BORING <br /> <br />, HYDROPUNCH, HAND-AUGER, OTHER*) fl DESTRUCTION (choose type below) <br />V&HriNICev +t ti 910- OA HC-) NI 600 <br /> <br />, GROUT SPECIFICATIONS <br />fl OVER-BORE. DIAMETER <br />l] PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'41 MONITORING IHOLLOW STEM DIA. OF BOREHOLE 0 ' 0 MULTIPLE CASINGS I] MULTI-LEVEL WELL CASING DIA: <br />1:1 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS (. i ,i.P(A 1 0 TYPE OF CASING: 1:1 STEEL 11,,Pvc 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL '-.3 7gc TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ---7-) <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1?/Ii\-01.1.e./ _.--. 1 ii4i- ; ( t' roi,o-i- 6 at ri-- I- 3' 04)S <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 7..-7 1203 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CqNDUCTOR CASING PROPOSED klb (if YES, list specifications in comment section) <br />COMMENTS: Ott .i tm0 7,(Atii(1,0 -\'c'li,1 --1-7-7' 1,2(ic, <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 />Print Name Y)CkE)4/ <br />Title/Company ,PV- (4)\ Signed x <br />/titg(Y* Date 5-11010 <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: <br />SITE MAP IN UNIT IV FILE, ADDRESS: /65C:70 .5. /410444.4e (Z•696) <br />WELL Location. AtMe/A7ticrosp street <br />-VI <br />ris(SLdressi 1-1DvIan City <br />VI Address -2)1(,..2-- ()rYtte, el( City <br /> City <br />Lti ro <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />Date Issued -73 --a5 Area623. <br />Date <br />Date -151 Date Final Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P BRAD' : CE REQ I INVOICE <br />.0.) *1/4) . 1:7 1P/3 <br /> <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit •7 EncehetrPee— <br />aer....e.40 art-4944 EHD 29-02-001 <br />6/22/04 <br />