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Date <br />Joaquin County <br />c <br />Environmental Health Departm SIT E <br />304 Fnst Weber Avenue, 3rd Floor, Stockton, CA <br />kcENE,Ini.T.ArioN <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application JUN 2 7 2005 <br />Application is hereby made to San Joaquin County for a Pennil to construct and/or install the work RittiTalkiESIin compliance with San <br />descjiBZR. Or os*NT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmenta Health Department. 43-/-7--.-errret--eit=ei— <br />/ q -25-6 , H (4) y 9 9 , Assessors <br />WELL Location lA /Es-anew 0,4. *SAP PiniA cross Street ei)Op L)13fil OaCity 4e. 0-tlio Zip PS 7C0 Parcel* 017 - c''‘ cp <br />PROPERTY 1 f -(/&t' She --ib F ex 7- o q 14`t'—i:a :51/4-1"1" 4,614a5P-honett 4,5v---54.9--r3---- <br />Owner 444‘714 (40.-•147Pr "FTPAd ress P.,,,-Lik-aA-ki City-P-orle4—G1 Zip <br />C-67 Contractor C-1 ke-99 - bl S- /44 Address 1- )" Z 1/0c1/111141- City 5:5 ,1,:i A il <br /> <br />Zip Lic#45°1-Phoneit C‘ Z ?? tRIct <br />Consultant / Sub Cntr to , le, &key', Pat P. a Address 61 t 0 MI Vo-)2,-0.1 PoCity A-.-6,4 ,-) Licit G *2/. 2 /0 Phone* S 30 813 2' S*-6 <br />GIS Coordinates: )._ 4..5/a r, , y 922V'0 AI , Township A P,..) Range 7 e Section 3 I <br />WORK TO BE PERFORMED: <br />o NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />U SOIL BORING ft Q OVER-BORE. DIAMETER <br />U WELL * PRESSURE GROUT <br />j-'Other 0.7 Ara ft, 4r1...- GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />O MONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS "'Al TYPE OF CASING: 0 STEEL a PVC 1:1 OTHER: <br />D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />fl AIR SPARGE/ OZONE )kPUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />irj OTHER: Il OTHER APPROX. BORING DEPTH di" -SC.) icr a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> <br />/9„5"reéX /`• s c <br />Signed x Title/Company A2 -6- 20 2/0 <br />DEPARTMENT DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />„ c) <br /> <br />Date Issued ..J(4 fUL U i Zak-) Area <br />Final Inspection By Date <br />Date <br />COMMENTS / CONDMONS: <br />ACCOUNTING ONLY: AID* <br />FAGS <br /> 6 s° <br />PE CODES FEE INFO AMOUNT REMITTED CHECK S REC'D 7 DATE MI REQUEST S ,114ICE 1 <br />, <br />.2 iqo ,- ,/ ; /- '6i.) <br />1--;--)E-AT-+4EltY10E <br />/Ac s R# 2-ef Z 3-7---- <br />C-57 <br />WC -WAIVER <br /> C-57 Letter of Autho zar o sign permit Encroachment doc <br />Print Name ./1-71;t0 Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />EH D 29-02-001 <br />6/22/04