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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 />342-c 314C <br />j <br />Address tot-ty _ Phone# lb 6qq z-z,6 Consultant / Sub Cntr Q-- <br />GIS Coordinates: X Y Township Range Section <br />WELL Location <br />Address <br />Cross Street C City Zip c1.5-3/42 Parcel# <br /> City Zip Phone# 3( <br />Address % Bc9k 53 (a-- City 40 Vi Zip/c/c7fLidt SY 6 PhOne# -707- 3.741 Lab 0 <br />Assessors <br />PROPERTY <br />Owner <br />C-57 Contractor <br />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 <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />WORK TO BE PERFORMED: <br />Ei NEW WELL / BORING <br />1:1 SOIL BORING # <br />I] WELL # <br />O *Other <br />COMMENTS:1)256i\ <br />II PRESSURE GROUT <br /> <br />GROUT SPECIFICATIONS <br />C % IOC k e..14)ccC-C"-.4' <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*)14)- ESTRUCTION (choose type below) <br />p&DVER-BORE. DIAMETER <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />41 MONITORING a HOLLOW STEM DIA. OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 1:1 STEEL 0 PVC ['OTHER: 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS U HOSE <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />U OTHER: a OTHER APPROX. BORING DEPTH g BOLTED TRAFFIC BOX or g STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 S,an Joaquin <br />County Ordinan es, ules nd Re, •tions, and all applicable California State Laws. A- 0- 4-\-)2_ GE) 4' 4 / Signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />COMMENTS: <br />Title/Company G'-Jo t7LT.V'c ) <br />Date 7/2-.0(0S— <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Stet 2 c-', 24)0 ( <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date Issued (elt Area / <br />Date Fjnal Inspection By Date <br />Date / <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />_ <br />/ SERVICE R S INVOICE <br />COVC-6 //7 /4 K- (We' SR# rOcte7 t2.3(, ) <br />— ..._ ... ._..__ <br />-7 Letter of Authorization to sign permit Encroac-riment (Toe -VVL.- <br />EHD 29-02-001 <br />6/22/04