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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Date Issued <br />Final Inspection By <br />Date <br />ORIGINAL <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.orgfehd <br />Well Permit Application <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />DtJ <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <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 olf4/S.artista,quiitin County Environmental Health Department. <br />2-qCt W. (Sob- Assessors . IA/a...y <br />WELL Location tit- 14r.t.u. I /I 70ciS--C) Cross Street 5t42.ne..*: City 5-kck4-0 vl Zip q-S-20s5 . Parcel# 117- 0 8 <br />PROPERTY <br />Owner 14rtie i-co Re4.4 Es4.4. , Address 2. N. C 444City Ph oein ;`),f Zip gg-t" Phone# 6c2--263 <br />C-57 Contractor (-rey) Address ciS-C OWNS City j46.4.nel- Zip R.C...C-3 Lic# 8.51 CS Phone# 92S- 3/ 3 - <br />Consultant/ Sub Cntr 13 lae 5 EtAte:rensi.e41 / Address P133 k. 3r-e4 tifre City Pttoc."in fx Lic# Phone# 60 2 72/'-c,-F•e? <br />GIS Coordinates: X 3711;32.S-0y ,Y /21.29-i6g 2.4/ , Township 72/V Range R6 E Section 3c <br />WORK TO BE PERFORMED: <br />NtIEW WELL BORING .„(qPT, GEOI:TOBE, HYDROPUNCH, HAND-AUGER, OTHER") D DESTRUCTION (choose type below) <br />II SOIL BORING # vr- , a OVER-BORE. DIAMETER <br />OWELL# AtAr- a PRESSURE GROUT <br />a 'Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />"(MONITORING a HOLLOW STEM DIA. OF BOREHOLE 8 a MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: 2- _ <br />U EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS °*15-4/ l' TYPE OF CASING: D STEEL APVC D OTHER: <br />U VAPOR a MUD ROTARY DEPTH OF GROUT SEALS 'e 1,dilr-of,„....-.s TREMIE TYPE TO BE USED: fi,AUGERS a HOSE <br />U AIR SPARGE/ OZONE "(PUSH POINT (GP or(tr4GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS A I e 4.4 6 . ---t- Tye_ 2.... <br />a OTHER: n OTHER APPROX. BORING DEPTH -S 'f IKOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />d; a. y al" c i k.,-, if ke ...7 . e a-4k,5 ,",,,,..4, ,14...,..__ ...?, ' <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 x Title/Company A MC1"1..t.,0 (LCA L. CebTiklc <br />Date 2Z 2.1 Fac, ote <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 4910 tax-D <br />COMMENTS: '47C tx-i-tc, rine t/t1_1 <br />4.7 <br />Print Name 9 06e-scr K crk.f <br />WORK PLAN DATED: 2. - <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERM CEREQUf ç <br />,35) f MW" Sg e 1-' 3 5 a4 31 R_it a 417,/ L., y..- . <br />C-57 Letter of Authorization to sign permit C-57 WC -WAIVER <br />END 29-02-001 <br />6/22/04