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Application Accepted By <br /> <br />Date Issued <br /> <br />Grout Inspection By Date Final Inspection By <br />San Joaquin County <br />Envir—imental 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 />frojc2, 30, 9 FA 2; 11 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made i confli4nbe vyrith San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental HealthII/eOrtieirkt.:( <br />kAki.i44)soitg <br />WELL Location 52-1 C 9 Cross Street Cdifbrild. 9" City 9-04--hil Zip 514 W-P--- 'Parcel# /31- <br />PROPER,TY <br />Owner C105 fati; ye 2 Address 1Z-S Wi Istftife C City -Nikodit. Zip11/52-1, Phone# <br />C-57 Contractor Itchia141e4 clecC-ou agiveraddress X37 'a i2 City Shik-A4 Zip 5Z/5- Lic# bV17 Phone# 47 -104 <br />Consultant / Sub Cntr eit0C-tt. viitittliPatti Address g27 %AAA, E-,4 <br />GIS Coordinates: X Y Township <br />City 51-116/4t4 Lic# 42PZZ7 Phone# b7 -11,4, <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />R.SOIL BORING # 3 <br />WELL # <br />[I *Other <br />O DESTRUCTION (choose type below) <br />fl OVER-BORE. DIAMETER <br />1:1 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />C-57 WC -WAIVER <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />['MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE iwfl MULTIPLE CASINGS I] MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />I] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4044-1 TREMIE TYPE TO BE USED: 0 AUGERS ['HOSE <br />B AIR SPARGE/ OZONE *PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pc le+-takkei <br />POTHER: a OTHER APPROX. BORING DEPTH £10 a BOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 />Signed x4.4 1,,k,—-41^ Title/Company 544 Oleo(0 eSis ) - - AlThau (.4 giez6tv , yea wean! <br />Print Name C4ifii4( L, Eist,,t Date 12--21 -OS <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: C2. <br />WORK WORK PLAN DATED: )2_coc; <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE „....P_FAMIT-1-SERVi6F-13,g_g_ INVOICE <br />2- ; LI 71- tlf 1/2.,1r< sRitvii 554-6 <br />C-57 Letter of Authorization to sign permit <br />EHD 29-02-001 <br />6/22/04