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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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliciiERIVW@ErRAgetrsice with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 433 Vo, 5w A1A-C Cross Street 14 ht-Of 11 City 5/veil...foi4 Zip qc-20 Parcel# °4 M7 -04 0 -0 <br />PROPERTY /44-- Owner !1/1070 \C-tft+t, p7f44,14Address I ()S W SWIMS+ ft-4 City Zip34272 Phone# (25-6 47 - 04 <br />C-57 ContractoraSdidi edhio3ne Address...Z.32 Orkte....C1rat City co Avg zip95712Lic#7/757 0 phon <br />Phone# 467-100(0 <br />Section <br />a DESTRUCTION (choose type below) <br />['OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />SITE <br />IL <br />UNIT IV <br />JUL 1 3 2005 <br />Consultant/Sub Cntr u'assi ("A Graq-rt,i/ Address 7 ShtlAu Pri citySlotaAi 1-idt & ga22-7 <br />GIS Coordinates: X , Y , Township Range <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />rther <br />LL # I.J <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />AIR SPARGE/ OZONE <br />SOIL BORING <br />U OTHER: <br />COMMENTS: <br />S <br />IA <br />MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: /) <br />CASING THICKNESS6C1A4b FVCTYPE OF CASING: 0 STEEL 'PVC ['OTHER: <br />DEPTH OF GROUT SEAL /2 I TREMIE TYPE TO BE USED: efrAUGERS U HOSE <br />U PUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes )14(0 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />1:1 HAND AUGER GROUT SPECIFICATIONS /00diatd <br />El OTHER <br /> <br /> .25 KBOLTED TRAFFIC BOX or a STOVE PIPE APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED /VII_ (if YES, list specifications in comment section) <br />INSTALLATION TYPE <br />OLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />['MUD ROTARY <br />CONSTRUCTION OLSEPE;r ICAU TION <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />Signed x <br />Print Name 'I) 01 in I e k.thitk 1o3.e k Date f / oS <br />DEPARTMENT USE ONLY <br />933 r5c6 <br /> Ar <br />Grout Inspection By ''i'1 -7/.P.1/0-5 Final Inspection By fv1,1a.lor Date 413240 l - <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P R UEST # INVOICE -,...._ <br />35b ( <br />356 3 )-79 1 -8/1/45/ S R# I+ 3 01 e›.--• <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <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 />Title/Company 'f_ij (n I C Ad Uatad 6re4Aril, <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Li lig 05 <br />Application Accepted By Date Issued <br />04 <br />EHD 29-02-001 <br />6/22/04