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Date I z-it`i icqv <br />Date <br />Date Issued <br />Final Inspection By <br />Area -6 Z._ <br />l44 AAA.- Date t <br />17-111(0t; <br />W an 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 ApplicilitiEC -7 P11 4 39 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR., <br />Application is hereby made to San Joaquin County for a permit to construct and/or install ihtilkolgq owl <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San JoaqbitiOrtiPMEDtprigaR <br />WELL Location /131S E. Pr Pk,ke- Cross Street City Do /1.. City <br />PROPERTY <br />Owner si 6it. I • 114-1._ <br />i"A ZCC" <br />Address il LIO'7 E. \nicki-4-100 4. City ...cc.Li-o" Zip ((97fc Phone# ()3-zo re <br />C-57 Contractor M;t-ct.e.A DA11;31../ Address TIO0 '4117(4,-e_ Aot. City f-n4.1.-- Zipq5-5153 Lic#6 724 1 Phone# (707WM -Idtb <br />Address . City Licit (Ac, 227 Phone# (Zoe() V67- I cc-,69 Consultant / Sub Cntr ,A <br />GIS Coordinates: X , Y _ , Township Range Section <br />WORK TO BE PERFORMED: <br />ElliEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />g SOIL BORING # a OVER-BORE. DIAMETER <br /># I a PRESSURE GROUT <br />O *Other GROUT SPECIFICATIONS <br />COMMENTS: ) mcA'At,r-1/49s 6-) &O' <br />TYPE-OF WELL INST.A.LLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ONITORING rgOLLOW STEM DIA. OF BOREHOLE ,'‘ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 1t: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS c_1,‘. Lto TYPE OF CASING: a STEEL frfc/C a OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 56' TREMIE TYPE TO BE USED: ir/(UGERS a HOSE <br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Erfes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 17cle, lb ?eck-LS eg.,e-rc-- <br />a OTHER: a OTHER APPROX. BORING DEPTH Rol 4rEcOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED iko (if YES, list specifications in comment section) <br />COMMENTS: <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 Ordin nces, R s and Regulations, and all applicable California State Laws. _ <br />SITE <br />MITIGATION <br />UNIT IV <br />Zip SZI <br />is made in compliance with San <br />lib Department. <br />Assessors <br />Parcel# --I oc -7 5— <br />Signed x <br />6. Print Na -3 1 CLIO-Lek"- <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1-- r G. <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Title/Company Si,ff <br />Date t2 —-c( <br />DEPARTMENT USE ONLY <br />ckA (00 <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE REQUES INVOICE <br />5-a I --I• 6 ' , ) <br />-.I r , 2- 41(1 La_ 12-Itit h SR# 4 ,:k 11(0 00 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04