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REC\E\vED <br />AUG MOTZETION <br />ENVIRONMEIUNVO <br />PERMITISERVI, <br />9.1.Juv San Joaquin County <br />Env: amental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: wwvv.sjgov.org/ehd <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 anent= of Sa Joaquin County Environmental Health Department. <br />WELL LocationN2 Al 5- (*-{5)- Cross Street 12/11 CitfCC66tZi <br />zApsasrceesilors/3.5,...2F0 <br />Owner <br />f.R <br />- <br />PROPTY <br />ft _ <br /> ±fity., _ -V-4,2erit <br />Lier 6314-tea-/>1*Idress 2031 Or0.4 4,31 "4/ - Cit& 5CL;Y'aZipq(j/12.-- Phone#2-e/ 48 7,3t? <br />C-57 ContractoCI5COA2_ NPVitic_9:1, Address ...14.).-vl-nec _ City 0:4400-Zi 24/2-Lic# 71257 e) Phonea6 63°. <br />Consultant/Sub Cntr Address 33--) cujt ex_ cit&ted%Lic# — Phone# ZegV67 /Z:6 <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />fl WELL # <br />fl *Other <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />, Township <br /> <br />Range Section <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE V imeifiMULTIPLE CASINGS rj MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS A/14-OF CASING: fl STEEL a PVC fl OTHER: <br />DEPTH OF GROUT SEAL 6D e12-% ENE TYPE TO BE USED: di:I/AUGERS fl HOSE <br />fl PUSH POINT (GP or CPT)GROUT SEAL PUMPED: fl Yes ZNI o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS POve-/-66,‘A <br />APPROX. BORING DEPTH fee, irgOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 1.4) La1/49IA- I Title/Company <br />Print Name 113) (C-Ct.-L.> Lc:1ft2 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ,n <br />DEPARTMENT USE ONLY <br />27471-- <br /> <br />2005 <br /> <br />TYPE OF WELL <br />1 1ONITORING <br />o EXTRACTION <br />fl VAPOR <br />O AIR SPARGE/ OZONE <br />INSTALLATION TYPE <br />XHOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />MUD ROTARY <br />SOIL BORING U HAND AUGER <br />OTHER: a OTHER <br />COMMENTS: 400 ;401(ty W6( 3 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />CIFA 4&.± <br />Date <br />Application Accepted By (A-...).4.A„„ Date Issued <br />Grout Inspection By kA'Annntii Date <br />Destruction Inspection By Date <br />Final Inspection Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE • - - E REQUES INVOICE <br />35-o 1 ti 1r '1 - 0 0 4. ctstyloill SR# 004 3 3 <br />C-57 Letter of Authorization to sign permit v" Encroachment doc C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04