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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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />Assessors <br />WELL Location 1 0 1-- c 0,,kk \A./A Su.n (xi Cross Street Mar k e .S;-. City 5A-dr, k +.0 el Zip Parcel* <br />PROPERTY <br />Owner Aiktoeso,wov.ed A5ivkc.tr Address lpti 1 V1/41,iae_. A J Q- • City Akbes-k-0 Zip q 5751 Phone* <br />C-57 Contractor V .5, tA) Den1 .-- 1 Address /00% C-14/ \ k- /et 4 City..Ts. el 4-ev, Zip 9C641 Licit /1°1 b LiPhone# ?I-" -7 1 — '1/co <br />Consultant/Sub Cntr lriro A 4 -te ,0 AeL114ddreSS li t Li AAtAi, 54.. City EScalo" LIG* Phone* 7 0 9 -83 k - ? 1 tce <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />*NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />SOIL BORING # <br />NOELL # AA) I <br />*Other <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 12 19" if-MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: '— <br />CASING THICKNESS (7L-14• "i a TYPE OF CASING:%STEEL ftPVC °OTHER: <br />DEPTH OF GROUT SEAL 0 (a TREMIE TYP TO BE USED: fl AUGERS Ai-HOSE <br />fl AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />HAND AUGER GROUT SPECIFICATIONS Ne.G0- (O(o reef <br />O OTHER APPROX. BORING DEPTH r-1- 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED I e s (if YES, list specifications in comment section) <br />COMMENTS: to ° cA 44- e %.) A-45 ,•• i-c4 e -ff> elo.p -11-- of qb Fed- <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 Regulation all applicable California State Laws. <br />(yeof”iss-16-Y"-ad <br />Date ?/30/c 6 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 20 .1) ec eoveev <br />OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />XMONITORING <br />fl EXTRACTION <br />['VAPOR <br />INSTALLATION TYPE <br />HOLLOW STEM <br />El AIR HAMMER/DRIVEN <br />jiLMUD ROTARY <br />['SOIL BORING <br />['OTHER: <br />Signed x <br />Print Name <br />j °Id <br />J.e cq <br /> Title/Company Z e A.A.c../yf <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />ivcx,/ <br /> <br />Date Issued <br /> <br />AS",4 Area <br />.i/10)94, Date 17/Zr/t0 <br /> <br />Date <br />Date Date <br /> <br />Final Inspection By <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID* FAG* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY -14ELIZEZT # INVOICE DATE <br />3'5" 35i3 <br />AtiR) <br />1,4)se <br />4c. 9 9 , i t. <br />/727, °- <br />1535Y <br />iGe)z? ( NrK 44 e r r - SR# 00 Li 6, 40 ( <br />A <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign per ncroachment_ doe— --- _ <br />DID 29-02-001 <br />6/22/04