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Signed x <br />Print <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />Date <br />Date Issued <br />Date Final Inspection B <br />San Joaquin County <br />Environmental Health DepartmLR I GI NAI SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgiehd UNIT IV <br />Well Permit Application <br />WELL Location 13821 14,,,7 1Z <br />PROPERTY <br />Owner ClAk.rli e_ LC.,/i1 A141;:lre: 13S21 J. Ow/ 12 City Zip 95ZYz Phone# 56,41 - ;Co /5"- <br />C-57 Contractor 0.1.4cLe_1 1 144i "4. Address -1e206 ilikr+te Ave . City Eo ICC\ Zip qs-sto Lk* C7 26 .(7 Phone# 607) '0 if --`70'ib <br />Consultant/Sub Cntr AGE Address g.-1 City Ste.,ck-1-0" Lic# (ocC527 r/ Phone# 1l Co( <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATMIllfp/ - <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatiorA in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Enviroprneotal,Heth„pepqrtrilent. <br />.` 0 Ni " assessors EiN Cross Street _C/AssczickVQ City ,6,1 Parcel# 2C--t.)0 -05" <br />1.0 <br />GIS Coordinates: X , Township <br />WORK TO BE PERFORMED: <br />ErNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SpIL BORING # <br />B'WELL # <br />0 *Other <br />COMMENTS: <br />PPP <br />Range Section <br />O DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />EK1ONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />0 OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: 2 <br />CASING THICKNESS LLf TYPE OF CASING: 0 STEEL f"PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 3' /0 ' TREMIE TYPE TO BE USED: fKUGERS ['HOSE <br />El PUSH POINT (GP or CPT)GROUT SEAL PUMPED: eesNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS +./1.2_ f eco.,) <br />fl OTHER APPROX. BORING DEPTH 2.51 /6 0' .}340LTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED v,r.. (if YES, list specifications in comment section) <br />INSTALLATION TYPE <br />lik)LLow STEM <br />0 AIR HAMMER/DRIVEN <br />fl MUD ROTARY <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, R les and Regulations, and all applicable California State Laws. <br />Title/Company KLE;v;.ra414.43,/0. <br />Date 5- 1 - csC.0 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /501 al, 44A/K /27 ie/t4VOthitto.3 (v. Lool4.7) <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P : . • ------'!"e-----a EST # INVOICE <br />363 239 2-1 C,A.,k , -,..-1 , SR# 00 4_ <br />C-5 WC WAIVER <br /> <br />C-57 Letter of Authorization to sign perm'lt V Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04