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ORIGINAL <br />San Joaquin County <br />Environmental Health Departmei;4qg <br />600 E. Main Street, Stockton, CA 95202-3020 -- <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />AUG 0 2 2007 <br />Z007 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Ys made in compliance with San <br />HEALTH, Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE i O bb,111 t4 LNMENT HEAL <br />',,k4I-USE113VICE4' <br />TH <br />; <br />Joaquin County Development Title. Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location c72- 7-0 / Al- Wit -irA/ Cross Street <br /> Assessors <br />City .5-f-C,c-k-lo.-1 Zip c./...C2C4C-Parcel# jj (12 <br />PROPERTY , „ <br />City II"1 aev1 .X Zip)500'1 Phone# (": 2_ - 26_3-66 Owner 1441-4, I / /-t eviefCc7 Address 21-2:7t- V <br />C-57 Contractor 6,e ) Di Address cis-o oc„ve_ ka . City./416(-Pittez-. Zip `1St Lic# Phone# -313 - 51(00 <br />Consultant/Sub Cntr B lexe„; ,...-tcdAddress PLI`i 14 -7-3 ,-tk Ave- City h-e,ijç Lic# Phone# <br />GIS Coordinates: X 4, `( Z. 50( .24 14-4- 2-"i Township -12-1,' Range fi Section 30 <br />WORK TO BE PERFORMED: <br />0 NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />`AWELL # V& a As 2_ 1-1- /3S34. 0 PRESSURE GROUT <br />0 SOIL BORING # <br /> <br />a OVER-BORE. DIAMETER <br />[] *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: ;: <br />fl AIR HAMMER/DRIVEN CASING THICKNESS 0 i I,S =7 TYPE OF CASING: 0 STEEL gPVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL -C-c-t• ci,,,, :_ TREMIE TYPE TO BE USED: AAUGERS a HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />J <br />0 HAND AUGER GROUT SPECIFICATIONS . Nei-I-1-- Ceo,c.0+ <br />0 OTHER APPROX. BORING DEPTH 5ce.... Pi,xir.L.fr. A BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />14LA \A}e_1( , F1, _J et c I For COMMENTS: S , <br />oc4.444,15. <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 ei..)\1 tillf\-4%-c-A_ Arviciv..0 <br />SITE <br />UNIT IV <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />XVAPOR( 5-) <br />RAIR SPARGE/ OZONE <br />O SOIL BORING <br />O OTHER: t/05011' N 101:t Print Name <br />SITE MAP IN UNIT IV FILE, ADDR <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />JLX Date z 0-1 <br />DEPARTMENT USE ONLY <br />Gl/i-LoTh — 1) <br />06P5/ Area <br />--Date /0--ios--o- 7 Date Issued <br />Final Inspection B7- <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE : *UEST # INVOICE <br />cicli oil 0-1 .1e 47 e 421? 6 SRpo ri V CiA,5f <br />C-57 WC WAIVER C-57 Letter of Authorization to sign per <br /> <br />Encroachment <br /> <br />EHD 29-02-001web <br />6/22/04