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ORIGINAL <br />Environmental Health Department RE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />i m 8,— TE <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br /> <br />Well Permit Application <br />OCT 2 UNIT <br /> LTH V IIMIA4TIION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EPVIERAPMENT <br />6 2006 <br />HE <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic ialAUErScompliance 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 P/ 7£/I AL -n.,,,,,f o r, RI Cross Street Crifil-e-1 Ave- City LOcill; Zip K2 42. Parcel# 055- /5 -2G, <br />PROPEVY <br />Owner I.)Ik TrA CAt Address ?6 6ox /o Ice ity TrAc Zip 75-374. Phone# .2 09 - i'32 -7780 <br />C-57 Contractor iiqf Address /016' keea-4eci -e-446"Zip 9:7-05 Liatell'irphone#NM057) <br />Consultant / Sub Cntr AGE Address ?3-7 SkgL..) gh <br />GIS Coordinates: X Y , Township 3 N Range 5C Section / <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />0 SOIL BORING # a OVER-BORE. DIAMETER <br />gWELL # V 14 - i , vw --a , v w -1, Av1 /4/- t , Avi - a. (fieth a,..,,,, 0 PRESSURE GROUT <br />G *Other <br />Atie1/7 <br />GROUT SPECIFICATIONS <br />COMMENTS: —14 <br />a <br /> CASING <br />VAPOR <br />: DCI <br />MUD ROTARY DEPTH OF GROUT SEALIV-X a 0 ' TREMIE TYPE TO BE USED: a AUGERS 0 HOSE .7.- <br />TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPEC FICATIONS 4i ") <br />O MONITORING OLLOW STEM DIA. OF BOREHOLE /0 a MULTIPLE CASINGS a MULTI-LEVEL WELL CAS A <br />: <br />-- <br />mAs <br /> a', <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS <br />OT <br />TYPE OF CASING: a STEEL PVC a HE 1 <br />LAIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') - .)., <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS .-?051-1-16.4 ell (0 Sack- <br />a OTHER: a OTHER APPROX. BORING DEPTH 15' + 0)5' 'BOLTED TRAFFIC BOX or a STOVE PIPE ot <br />---...) CONDUCTOR CASING PROPOSED N 0 (if YES, list specifications in comment section) <br />COMMENTS: le bor,ve,3 cor SVE_ d- 9" inorins c or TA S <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby ce th t I have prepared this application and that the work will be done in accordance with San Joaquin <br />County 0 • a • es, Rul- an -egulations, and all applicable California State Laws. <br />Signed x AlWAle.ilLoi.-111"- Title/Company A5en-1- Nc_)c- P G <br />Print Name Ckr . :1 ler Date <br /> <br />San Joaquin County <br />City ST Lic# 6 8027 phone# 10 0‘ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />N71-/r theee.- Ar <br />7-6 oc.ro <br />Date Issued <br />Final Inspection By <br />Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNTREMITTED CHECK # 'D BY DAT INVOICE P — -,- P..-"‹. ' <br />go,‘—, /4W/ j.;> my.- 740, to , si, MIS)117-Or' <br />C-57 WC WAIVER <br /> <br />C-57 Letter of Authorization to sign perm rit-d <br /> <br />EHD 29-02-001 <br />6/22/04