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SITE <br />MITIGATION <br />OR <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: wwmfrsjaptv.clra/ehd <br />ri rr ? 1 A t-I tu. o Well Permit Rppn6afion <br />C131.11. <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM oxre f*ED <br />- <br />Application is hereby made to San Joaquin County for a permit to construct ,and/O(install.the Work'deSdibed. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of 8an'Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 230 Z Wes T L AAIE Cross Street &PING- city S-7-ocKicw4 zip (/5 -2C2 Parcel# 11165-63 7 <br />PROPERTY <br />Owner —9-11>l 4-eitaidY c 4117/Address 2.0. DX 32 City S7bC7bn/Zip957.70/Phone# 2050 270 7 <br />C-57 Contractor /S" I Address 2.2o AL C4S1 ,s77 City 4/0oZ,AA015p7S7 Lic#YOZ013Phone# S..70 4.6(2?efi <br />Consultant / Sub Cntr j Tc- SSoc MrES Address 1/17 1.0NC P&i A4/6:ty imol•drK;Dcit Phone* 70? S7P <br />GIS Coordinates: X , Y , Township Range Section <br />W9RK TO BE PERFORMED: <br />'NEW WELL / BORING (OPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) I] DESTRUCTION (choose type below) <br />tIL BORING # .S-/ X 0•002-/N4S 0 OVER-BORE DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />'KUL BORING <br />a OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1/1OLLOW STEM DIA. OF BOREHOLE/ 0' ' 0 MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS A,/ 4 TYPE OF CASING: 0 STEEL 0 PVC fl OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS Cer-16..7 clap <br />OTHER APPROX. BORING DEPTH C ' ['BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> <br />Arc (..),,,c,,,Gb4 itt Vi Vo 6. AP-41 4.P oAK-PI.A eo ADAC Ahlu.) 3/1 rd-• COMMENTS: SE C <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 a R ulations, and all applicable California State Laws. <br />Signe <br /> <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 C N' rfin We- bt Lan -e- <br />WORK PLAN DATED: M a ITI'l 1 (el 26 0 <br />Application Accepted By <br />4- <br />VI el r ict L . McCarble-A-1 Date Issued A rii I 26 2-00 (.., Area 14 <br />(t <br />S-1 <br />Grout Inspection By if, 01416fa,t4,,4,,,, Date b" - -G3-14, Final Inspection By / / ,_ p ate 5-- -24t Cr C <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: A Vij Y1 e..0, 7) e: 3 I- 0 C ._!.; a)( so ; 1 kJ ti i '1 i) 0 S 0 CI r!/ I. f c-', . <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY INVOICE DATE RMIT / SER ST # <br />.3 5 O 3 119 ?GS SR# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroochndci- <br />Title/Company RA" fec.r/ c; e 04 0 6/ S <br />Date <br />EHD 29-02-001 <br />6/22/04