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I hereby certify that I have prepared t <br />County Ordinances, Rules and <br />s application and that the work will be done in accordance with San Joaquin <br />Ions, and all applicable California State Laws. <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Title/Company <br />DEPARTMENT USE ONLY <br /><1,2,4 1/6,,:11, ,t,i-67 I <br />6 - 1— <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By Date <br />s'd <br />Date Final Inspection By WAIF <br />44. <br />-.w <br />Area <br />re —/0-11 <br />COMMENTS / CONDITIONS: <br />Date <br />TYPE OF WELL <br />a MONITORING <br />EXTRACTION <br />U VAPOR <br />INSTALLATION TYPE <br />HOLLOW STEM <br />I] AIR HAMMER/DRIVEN <br />U MUD ROTARY <br />111111110 <br />/74/ '''/'(-71/1/4,•,c.. <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 />'9 <br />' A 2Assessors <br />WELL Location 7 f7 Cross Street 1(tlict1e, T•xl City 5-1-VC.1/4-)riSin Zip q9-2.0 4"-Parcel# <br />ex-k- 3 Z. PROPE 5- <br />01i Co Address / 31/6 -1-hyte.4.-/#"gy t.ri-r,FerZi.tp)65#1 Phone# I '55-W <br />n <br />Owner <br />\ <br />C-57 Contractor 7e5 A-- A ,,,„Q /fat D(.1 (gal ress Elf-cc-4RA, Are City Avv:_heiv- zip612-136-Lic#R/15Y3 Phone# 7/ Ile ?)41 6 5-0 <br />Consultant / Sub Cntrttlii/Acj 4,450 44.4kekddress 5-7/Z- r501.4. Cityck' Phone# 70, 896 C ele <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />)131:NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />>ff,SOIL BORING # 1 a OVER-BORE. DIAMETER <br />a WELL # a PRESSURE GROUT <br />U *Other GROUT SPECIFICATIONS '-k-- <br />t - 1 A 6' <br />COMMENTS: Ok e. ,,/ .5r;s k '50,--c <br />i <br />, (131 ) -ct tot-) <br />-i-S. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:_ <br />CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: )1c6UGERS AHOSE <br />U AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 'Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> <br />',1iSOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />U OTHER: fl OTHER APPROX. BORING DEPTH <br />-V, TV COMMENTS: . v <br />j <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />.1\ro <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE, P UEST INVOICE <br />54, ,._ '?7. 9col- Cai -4-/ syt 665/m-b <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA95202 9 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov 200? <br />Well Permit Application <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />£70' <br />U BOLTED TRAFFIC BOX or a STOVE PIPE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001 <br />6/22104