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Seot -11-litts ire san Joaquin County <br />Environmental Health Department Ctirt- <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 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 />Joaauin Cuntv Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />al ..1-imo,_-3-11_ Assessors , , „, A.. <br />W L Loca ' I oi-2_ Mir 11t1A-E' a-c-A • Cross Street 600,14,+:,,i DrCity p-, pre—% Zip 7534 G Parcel# 21,0104uu Li <br />PROPEATY <br />Owner (Arpin jv Address 13410 MCIOSSA., City5A4AIWS Zip (IWO Phone# 650-13/6-0q56 „ <br />C-57 Contractor Min Address IND title 1't City it44164,12.-zip qrSOLic# liesmoh,..- <br />one# q2.5-3/35134:45 <br />Address 15TO MIA 9. 54 e A City FilerYile, Lic#411053.2, Phone# g40 itagi3 Consultant/Sub Cntr via, <br />Y , Township Range Section <br /> <br />WORK TO BE PERFORMED: ---- <br /> <br />*JEW WELL / BORING GEOPROBE, YDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />Ig.G.OIL BORING # <br />11 WELL # 0 PRESSURE GROUT <br />0 "Other GROUT SPECIFICATIONS <br />Li_r_frikeir6t15 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />U AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />II SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:0 OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a 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 Ord' anc s, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company r. G-fa‘f-e-- eeo <br />Print Name eedi1 AA..-13eigekrc <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: in 2, 2, ry-c,-,14-4 rkd . S Si-e2 +e Ea.S r <br />WORK PLAN DATED: 7/02'7/ at <br />Application Accepted By V; r L . 171 e ZIA l'471,C - Date Issued <br />Grout Inspection By-(/iek4A_4c?VgzV:'a Date .9—.2 - O 7 Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS• (hiF(P1 )onrr )i/..e; f: kic r s <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE I,T311/1Ij_LBERVICEEC_B OICE <br />7+,0 0 K' SR# c 0 4 c i 4 e, 7 <br />MITIGATION <br />GIS Coordinates: X <br />OVER-BORE. DIAMETER <br />COMMENTS <br />Date <br />0 7 -62-44oftg <br />7 _ Area — .2 f <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign perm <br /> <br />111 <br /> <br />EHD 29-02-001 <br />6/22/04