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Application Accepted By Date Issued <br />Final Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />CoIrs ft-z //ref <br />Grout Inspection By Date <br />‘€)/° iz).• P I <br />RECENED ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OK) ,• <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 />WELL Location Yostolik A-ve. Cross Street 14W1 City Milyi Zip 1 )k) Parcel# <br />a c Assessors03 10 <br />Owner <br />rETe I /16 Lo <br /> Address q Logietliiro. 4 Di‘ City Lt{ inci 1010 Zip Cid‘ Z 3 Phone# q 25 - less <br />C-57 ContractorlAkOutAg,J Dr, I Ill £D . Address 550 Riwi p, City RiG V:3 ,i Zip I Lictrikk 7 i Phone# 70-37 4/ -41306 <br />Consultant/Sub Cntr 5 IraLS FAVPJW1 Inintid) TvILAdditiP 6.1141'0,A Rik Dr •y 61.4earl Lic# 15('S 47- Phone# 5341-616-2()6Z <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />G NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />WELL # <br />0 *Other <br />COMMENTS: pie 55,1"? ( w-614) itk) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />*MONITORING XHOLLOW STEM DIA. OF BOREHOLE fl MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS fj&er eltl,-671.1r- <br />0 OTHER:0 OTHER APPROX. BORING DEPTH [] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />..1 CONDUCTOR CISIVG PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: t'-< WOK") 14 \ d% ti' r -Jr a; j Itima oj 5JL, EN,D. oryk S-4-06, <br />NOTE: OFFSI E 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 Ordinance Fules and Regulations, and all applicable California State Laws. <br />Signed x 5 (ba .5 Title/Company 6 eo 105i )4, iijs Fcm cJii yr4vid, T"ei <br />Print Name 5i,c 4 6A. 1,21-- Date (1-2 -0C.' <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 7-2-1-0& <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES 1 FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE - ? EST # INVOICE <br />f'4‘)2--- WD 60 /2475 I ep, /t—b '06 4 -.e___19 041 <br />NOV 6 2006 <br />ENVIRONMENT HEALTH <br />PERMITtSERV10ES <br />SITE <br />MITIGATION <br />UNIT IV <br />\F(DESTRUCTION (choose type below) <br />OVER-BORE. <br />NjPRESSUREff <br />GROUT <br />UT <br />evo 61, uptiq 5- cgsi.-9 <br />/71( <br />osr-frk,-&- /14-774