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WELL Location 2-4 L 0 On c.O.V <br />Cross Street 1-x-\'s <br />San Joaquin County EFEEIJVITE-2-,0 <br />304 East Weber Avenue, 3rd Floor, Stockton, <br />Environmental Health Depar tment SITE <br />CA 9526 0 5 ?ON MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgo , Y'Rrg/ei/ttil HEALTH <br /> UNIT IV <br />Well Permit Application ''SERVICES <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />Assessors <br />City -11/4--o(N.-1<tyrN Zip S <br />PROPERTY S <br />Owner Address o ---;°r- City'C.( Zip r1iLTPhone# <br />3 Act2- C-57 Contractor ‘k•1.-‘5 Address .1v '1 1- c cvNe.s... r-c-N•si.. City c.,t.-.-Nc.Irs Zip caec Licit Phone# <br />Consultant / Sub Cntr Address t Sc,c_.,‘,3 Licit Phone#(\,c) CC-1-ok <br /> <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />likWELL # 'cr\ teo vsYNAurt. r•%t..-P44\ <br />U "Other <br />SOIL BORING # (_D‘") - - L C:vsc3A2Kpc c <br /> a DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />%MONITORING ponovv STEM DIA. OF BOREHOLE `4S '' ['MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2.:' <br />0 EXTRACTION l] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL PVC 0 OTHER: <br />U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL - '-k 4 TREMIE TYPE TO BE USED: a AUGERS ,HOSE <br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes ct No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING a HAND AUGER GROUT SPECIFICATIONS cV\4',---- k-A --- "S -)• \,.....-kc,..-w <br />U OTHER: 0 OTHER APPROX. BORING DEPTH ..--'•---\'13'-\ ILBOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED — (if YES, list specifications in comment section) <br />COMMENTS: 's ..:, , \ \C3 '-'<- SC) <br />. <br /> ;•(X-Ar- — '\4> — `--"Ctli,--k c y'V-,(,(,, \ sict3 'k'3 ck-,-4 <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 and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br /> <br />Title/Company IR RA"C\r, 41- \ <br />Date q <br /> <br />Parcel# tj`1 2 S <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 5? 2-1 [CIL <br />Grout Inspection By tAAiv.".c.o-u•- <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />2.4 2_ Smi-f s -I • <br />Date Issued I ) <br />Lit CA.._ Date 1/2-/o <br />Area Application Accepted By (A t.idinnern <br />Date I 2--M /07- Final Inspection By <br />Date <br />COMMENTS / CONDITIONS: C.- C> 5 £,mrM4 to.e,w.„,4---tE- 16 99 S t 3/.4 <br />ACCOUNTING ONLY: AID* F Ac# ck DO q35 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE - ' - . i # INVOICE <br />cits-er- 00 .00 z asts•he AC , 1 icia-7 _ sR# 4 c3 s <br />C-57 <br /> WC -WAIVER <br />C-57 Letter of Authorization to sign permit I./ Encroachment doc <br />EHD 29-02-001 <br />6/22/04