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....... <br />„ , <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />pp.smEN-r, ORIGINAL „cEivE <br />......... <br />ni SITE <br />c-Eg 2 0 2-°1VIITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd AclumcouwAJNIT IV <br />spay JO ...,..sviart Well Permit Application alr'6EpAvittliew <br />Cross Street Ave <br />Assessors . <br />City fr*ex:#7eiv Zip ..52477 Parcel# 5, -/Z <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "eAL <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 23 09 N. <br />PROPEVY <br />Owner 61/77 / c7-06,,4'70,V acheloo Address City --(7-66 :4141 Zip 47-5-24)4Phone# i-a(7 37 if / <br />C-57 contractor 'Pecrt,(//11 a. Address 07/4 A401 og. City 5-/X,ela4Zip9P4S-Lic#s'/2248 phone# oq 1/66-g7/° <br />Consultant / Sub Cntr 4e71/GC 61/44f/0464ddress -c-1,..../4=24•6- City /6177,4Kic# C 57-76)7 Phone# 72q5/14' <br />GIS Coordinates: X <br /> <br />, Y , Township Range Section <br /> <br />W RK TO BE PERFORMED: <br />K NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) rOIL BORING # <br />WELL # r - A4(A) 7 Sci-t2 //VW) os 4-c. <br />a *Other <br />a DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />\,1•1 <br />COMMENTS: <br /> <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'If HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS Col TYIPE OF CASING: °STEEL ''PVC 0 OTHER: <br />O MUD ROTARY DEPTH OF GROUT SEAL3I3 4- 7er TREMIE TYPE TO BE U ED: *UGERS fl HOSE <br />p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: )Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br />a HAND AUGER GROUT SPECIFICATIONS 570 io,„/H 2 0 i&g. ?4' -4 6-6-7-3-1 cc, iv-r- <br />a OTHER APPROX. BORING DEPTH SS-I 4- éY I4BOLTED 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company C/ ii/L-61/4//veeie cotima r-m1-uvc,/4,4__ <br />VGAGN Date / <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />0 OTHER: <br />1k <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: (-5.- 7 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />14 /5 Ai. <br />35.03 <br />AZ/v• b <br />Area a PC1 <br />6 -to ate <br />Date Issued <br />; Date Final Inspection B 0 <br />NIIAMIWY Date asor.....!.•r. <br />COMMENTS! CONDITIONS . .....) i EXe--0."7107- <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE <br />603Att /WI t..9 7t,ti ` t L 1-) 3 t_-,- <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit Encroa <br />"-Wee •oz,Lo