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TYPE OF WELL <br />0 MONITORING <br />O EXTRACTION <br />7(;VAPOR <br />INSTALLATION TYPE <br />OLLOW STEM <br />O AIR HAMMER/DRIVEN <br />U MUD ROTARY <br />ORIGINAL <br />Environmental Health Departmenh). SITE cV 600 E. Main Street, Stockton, CA 95202-3029 -gNIITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV AUG 14 2007 Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS WRONMENT HEALTH <br />TER MIT/.ERYIC ES Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app 'c i i ation s made n compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards ,Qf San Joaquin County Environmental Health Department. <br />KR, in ON/c. , E Assessors <br />WELL Location q /05 Avcnv(-Cross Street 13,',9•Axo, RD, bity S ToCK •ThAZip 9 5.?4 Parcel# <br />C-57 Contractor Pi )1 A di) c) Address 79Q0 tl pril . City E rtz,k 4ei Zip 95503 Lic#(67.76/7 Phonek%ri ) 9 Y 90 Yo <br />Consultant / Sub Cntr iG Address 3 7 c.g+A.„,v R0 <br />Owner ,J,13;41 C'IQ Address Yo 5 /9'/Q.—City S70(K 19/1 Zip 95'40-7 Phone#(29)9 M <br />PROPERTY <br />City 5 ick...K re‘Lic# 408 Oa 7 phonokst) Y& 7- /go <br />GIS Coordinates: X 3.1%, 6igS y -1. 3 t , Township Range Section <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # <br />AWELL # UtA1.4 3 <br />0 *Other <br />COMMENTS: 5F-- E RAD -412eRoue0 <br />CONSTRUCTION SOTFRBUOCRTEIOHNOLSEPE/OCIF,,ICAJ MITS IA <br /> <br />TIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />sc.ir.o-4) t <br />CASING THICKNESS y cr) TYPE OF CASING: a STEEL *VC a OTHER: <br />DEPTH OF GROUT SEAL Co ' TREMIE TYPE TO BE USED: )AUGERS exi-IOSE <br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 'Jo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 10.„RTLAND -Filet_ <br />a OTHER: a OTHER APPROX. BORING DEPTH 13-- i 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CpNDU.CTOR CASING P IR 0 P 0 S E D N a (if YES, list specifications in comment section) <br />COMMENTS: 5E-E- Eto pfeAa,A) lci-kr c.4 A-TE 0 oR \:)\InE, 2_,.(\7 <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 gulations, and all applicable California State Laws. <br />Signed x Title/Company T9401)QL-1-- PAN/K7E e <br />Print Name —77N) T/3 C D8// t/i/ <br />DEPARTMENT USE ONLY <br />cicitY5 SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: • 7 -0 .1- <br />Application Accepted By Date Issued <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />, <br />sW Coat 7/ 6 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERV INVOICE <br />3501 WI 5,0-' 2100 5o 0,4,t - 14 SR# <br />C-57 C -WAIVER AVA C-57 Letter of Authorization to sign permitOK Encroachment doc NA/ <br />EHD 29-02-001web 7-0072e.,ttzt 466" <br />6/22/04 <br />San Joaquin County <br />0 DESTRUCTION (choose type below) <br />o OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />01 c. D.--)-Ro Or, iy 2-00 7 cohh Area Ii6eq <br />Final Inspection Date - Date