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PERMIT/SERVICES <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9(1.3. <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />1 2005 <br />Well Permit Application ENVIRONME:N1 HEALTH <br />Consultant / Sub Cntr A .c 1E . Address S!7 ski v., RO City 5 TM/41.9 A LiC# Et Z 7 Phone#1.0 v <br />Section Township Range GIS Coordinates: X , Y <br />WORK PLAN DATED.: 5- I- 2-co <br />SITE MAP IN UNIT IV FILE, ADDRESS: Ot* -Lap <br />Date Issued Area <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit En,st.o. ertfimentylete-- ote_ I f <br />Ace es dot, " t <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />orr/aacie <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 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 1-111 /5 Ave. Assessors hV 42.• Cross Street V, /3; Arvcrh" R.p City 570c IC ?on Zip ciS a -7 Parcel# <br />PROPERTY <br />Owner A/ K MA N4551 tO Address I t4 9 t L,,, City L-O,Zip 952Y Z_Phone# 000 344 EV 7g- <br />c /4st:f4at thlz ,'N C-57 Contractor Address 1(432.- Om k. C(rc City AecivrcP4 Lic#7,75-/a Phone# /11) (0 Th -/ OP <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />1:1 SOIL BORING # <br />ELL # gtv I <br />Other <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE leU MULTIPLE CASINGS <br />ol <br />MULTI-LEVEL WELL CASING DIA: la ;Lilt. 10 CASING THICKNESS TYPE OF CASING: U STEEL ,IcVC OTHER: <br />DEPTH OF GROUT SEAL I TYPE L I TREMIE PE TO BE USE b: rAUGERS U HOSE <br />PUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes (No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />HAND AUGER GROUT SPECIFICATIONS Pot+ !ley() Tip& .f- <br />0. APPROX. BORING DEPTH 'I OTHER XBOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED CI (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 /> Title/Company Aas; A/19 Va f."-- <br />Date 01/ 13 5 <br />0 <br />COMMENTS: (Arc.) K PIA Ai 4dc.ev <br />0 DESTRUCTION (choose type below) <br />fl OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Z-i MA rt. 14 <br />TYPE OF WELL <br />U MONITORING <br />)(EXTRACTION <br />['VAPOR <br />fl AIR SPARGE/ OZONE <br />SOIL BORING <br />OTHER: <br />INSTALLATION TYPE <br />'XIOLLOW STEM <br />AIR HAMMER/DRIVEN <br />MUD ROTARY <br />Signed x 7C.4•14m1\ <br />Print Name 7,7,„ Cv04.t" <br />DEPARTMEN USE ONLY <br />_c <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />----------__ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST ' INVOICE <br />el <br />5 . to-to C__s!,R#4610 P <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Final Inspection ,_Date 5 Date <br />Date