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Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />/1) e sued <br />F I In ection By <br />Date <br />Date <br />San Joaquin County <br />Er -onmental Health Departmek <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 Applicatilft5 AUG i 1 p 3: 54 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT,E,IsspD <br />;jTy Application is hereby made to San Joaquin County for a permit to construct and/or install the wkrkttegicklAid,10-9TwElication is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin CcitiEtAfEnTODYEeintfidittiffitt Repartment. <br />WELL Location Uz._ V ki 1,._ <br />CLAJ VVCil Cross StreetS5i14.1 — LY City 'AIX icrcki Zip (K21)-1-- Parcel# <br />r Assessors <br />PROPE <br />\ <br />RTY ,) • <br />Owner V\IT, I \ 17' It)sr A-tt.rA viACL Address 41f)7 MC/4"..5i'N City Ski, Lied., Zip (67/5 Phone# (-2:/())461- —e675" <br />C-57 Contractor 4Pe52 Poi 105 305110Address 90/11VW Paid city ire, 01 zip94.3Licliab 07 phone‘975 )313-3-800 <br />Consultant/Sub Cntr N./kw/kali Cri3E".) Address Si/vA3 ir-01 City 10(_1(fGAI Lic# &qui 2- 7 Phone# <br />GIS Coordinates: X <br /> <br /> Township Range Section <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />WELL # <br />*Other <br />COMMENTS: <br />Cii}r <br />0 DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE.2 if 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: tdif" <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS &VA TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ....41/:-; r-t_ TREMIE TYPE TO BE USED: 0 AUGERS I] HOSE <br />URIR SPARGE/ OZONE USH POINT (GP or CPT)GROUT SEAL PUMPED: es 0 No (NOTE: MAXIM M FREE-FALL DEPTH IS 30') <br />)(SOIL BORING 0 HAND AUGER GROUT SPECIFICATION'S "ri ii, kizt e.:,.. ; 1,,,:‘, 4. (-- /.., z .,_ frf)/ 1.0 <br />O OTHER: a OTHER APPROX. BORING DEPTH "CC ' a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED AdiC) (if YES, ist3pecifications in comment section) <br />COMMENTS: ta y i-ed AL,— (At) (s h0/193 Cit.' ed 4 iz cy:),--- e,„,k,,„, , <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 /> Title/Company <br />47 \ tooLc <br />67,-40/i--61.c1 <br />Date <br />Acio&,.(9/t-v <br />(lobs <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AID# FAC# , <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE. P - , T/ SERVICE REQUES • INVOICE <br />2- .,./, ) 8 i / <br /> sivtuot.4 <br />I <br />C-57 WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorizatio..fo sigh permi <br /> <br />Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04