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San Joaquin County <br />Environmental Health Department <br />SITE <br /> <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNIT IV <br />Well Permit Application <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 />Jo in Cuntv Deyelopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Orl -..) ifv.C, `rt.-4.4.:11-1-PLA.2..-/St AssessorsPameItid. 1 02.01 z_ <br />L Loca • 1CM, rerrIftle. PK • Cross Street Gine, 414,, a Dr", City ?Ion zip9.5344 <br />Owners/wpm Address ow Room, citysioomtus Zip qt1010 Phone# Q93 --ler-0(15-6 <br />PROPE'ATY . _ y • <br />C-57 Contractor Dillin Address dig) 414.06 let) City 141411/112.-Zip q1M3Lic# lieSbrhone# /253/3513 CO <br />Consultant / Sub Cntr -a. Address 75110) fialts 9. *A City SierYlit Lic#1102,. S7,. Phone# 5101a.4.7)..3 <br />GIS Coordinates: X Y Township Range Section <br /> <br />WORK TO BE PERFORMED: --N <br /> <br />*IEW WELL / BORING GEOPROBE, YDROPUNCH, HAND-AUGER, OTHER") a DESTRUCTION (choose type below) <br />WOIL BORING # a OVER-BORE. DIAMETER <br />-a WELL # a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />r__PrAbt__601N5 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br />U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />U OTHER:0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 Or ma ces, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 5r• S 41402 ktcyCairtin <br />Print Name Ceti f—IZt najj/2•2_ Date S—teAP <br />COMMENTS <br />9-) <br />DEPARTMENT USE ONLY <br />) Ci 22. F r fe <br />artA ci/a7p26 c1 <br />ko 429 e <br />INW1Ar 4 <br />Date <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 7i251 o <br />Application Accepted By Vi r 4 L. <br />Grout Inspection By Vi ciTY1 " <br />Destruction Inspection By <br />Date Issued I) 1)7 Area II ' sl <br />7 Final Inspection By <br />, e 157 0 7 <br />COMMENTS / CONDITIONS: ,r) e', CT )20 .7) S <br /> Y-ok,e ioor <br />ACCOUNTING ONLY: <br />. <br />AID# FAC# <br />(..../ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE 1.....:-___,ERffla../-S•ERI.WA-REQ11 S'.E_I.*& IN CE <br />3 50 i <br />3 57) 3 <br />7 <br />,2es- .374 00 C SR# 0 0 4 9 6 6 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ncroac ment doc <br />EHD 29-02-001 <br />6/22/04