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San Joaquin County <br />Environmental Health DepartmeitEC <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/410.1 3 02Q06 UNIT IV <br />Well Permit Application <br />NEDCINGINAL <br />ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUPERMIT/SERVICES <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 />P44.444/1City-Ttiole{11- <br />Assessors <br />0 zip 6tn0%, Parcel# 00 1 — WELL Location 1-1/2-6t, t\bilnic I t2-,e1 <br />piroellne4-S PROPERTY <br />Owner WillVcA/sot I FD keS4 A Address1-0%1 Nr.-- City GIVA141 RivrIS Zip 41525. Phone# (01 v—scitl--frivi <br />C-57 Contractor WO °el hho v-4 DVIIII17.1 Address Re'. 0 X S Co City RIO VIS4 41 zip c14 5/1 Liairnoolq Phone# 01) 374 -43crt, <br />Consultant / Sub Cntr IC--e" Address F: 0 • a X 141 2-(g Crt:lac-viv Lic# C,0341701 Phone# C5-I ) <br />GiS Coordinates: X <br /> <br /> , Township Range Section <br /> <br />Cross Street <br />MIRK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) a 5OIL BORING # a OVER-BORE. DIAMETER <br />VWELL # Mvs/-1 -2-, i -3 0 PRESSURE GROUT a *Other ) i t DM ..51M / GROUT SPECIFICATIONS <br />COMMENTS: <br />TY/PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />q'MONITORING HOLLOW STEM DIA. OF BOREHOLE cli" iMULTIPLE CASINGS 0 MULTI-LEVEL ,WELL CASING DIA: 1-11 <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 0- 01 42 li TYPE OF CASING: a STEEL f 'PVC j0 OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I ' - 1A7 1 TREMIE TYPE TO BE USED: .1"AUGERS 0 HOSE <br />()AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: -0/Yes 1:1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />['SOIL BORING ['HAND AUGER GROUT SPECIFICATIONS NI CA 4- Cc-riii c-li 4-• <br />0 OTHER: a OTHER APPROX. BORING DEPTH 4 5" 1 1:40LTED TRAFFIC BOX or 0 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 />Title/Company pl/Ikte-11,,i I 1,11s/111 / I 0- e <br />Date I-2-4-o tif <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br /> 24 z—oo )\sr) czi ap DEPARTMENT USE ONLY <br />WORK PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />Signed x <br />Print Name e-rii L o ii1 <br />Date <br />Date <br />Final Inspection B <br />61- o,6 Area <br />NON <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE ERMIT / SERVIC T <br />1-7 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit rthinET <br />EHD 29-02-001 <br />6/22/04