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gan Joaquin County <br />W-FD Enyirc,nental Health Departmen SITE <br />600 East Main Street, Stockton, CA 95202-3029 -rp 19 Hp MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgad UNIT IV <br /> <br />Well Permit Application ENNIRONMENT HEALTil <br />PERMIT/SERVICES <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 />Assessors <br />WELL Location /6c. ectse";4rAvc Cross Street Ani:11,n_ggajCity -/c40%. Zip f5-3 <br />„ <br />3 Parcel# Z/ -02a -31 <br />PROPERTY <br />Owner A•14 11..S II., Address Z?2.1 pe 1,h le D^'-ei fy beZilp °74".-- hone# <br />6-1 <br />C-57 Contractor AT/177—,, i-rczttAddressi.s-04ç E.riJ City 1-4c./4/•steZiP7fS3) Lic# 4T.S6ro1Phone# <br />Consultant / Sub Cntr -it'4"1/3 riLsIcci-ciress 1 9 Y if,'Lier-s;,ic Dr City cz)ncvw-LiC# <br />2-3 <br />Phone# -707-133-22 4 7 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (CPT, GEOPROBF HYnPoPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />X.:SOIL BORING # CAT-14 a OVER-BORE. DIAMETER <br />- a WELL # <br /> ORIGINAL a PRESSURE GROUT <br />D *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />cD <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2. a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: PA_ \S\ <br />0 EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS 'VA. TYPE OF CASING: a STEEL a PVC ALii-pat <br />O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA 4.4. TREMIE TYPE TO BE USED: it HOSE <br />0 AIR SPARGE/ OZONE VUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ---' <br />ASOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Az- 4.,,./ -Vrz z e-",....b "\--' <br />, <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 60 ce- a BOLTED TRAFFIC BOX or 0 STOVE PIPE ,- <br />CONDUCTOR CASING PROPOSED iL.10 (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 preppred this application and that the work will be done in accordance with San Joaquin <br />County Ordina s, Rules nd Regulations, and all applicable Califorrfa State Laws. <br />Signed x Title/Company req9Y7 / <br />Ma4-11 toa 140 / Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I I 1, 0 W . YOSern;+e., <br /> <br />WORK PLAN DATED: Macy .24 2(70 17 <br />Application Accepted By V; GAir f"' A_ L x in /I 64 Date Issued Q ej-h 6a,. 3 i• 240'7 Area / 4 S-ei 72..) _, <br />Final Inspection By 6../Zr',4/2.Aii71441!-/../72‘.)Date ?/- /Z C ? i c.. ) ]) <br />Grout Inspection By ' /fit z,t, /rne:a1,11-2,47 Date _,' <br />Destruction Inspection By Date <br />COMMENTS (CONDITIONS: ACi Va CPT -1 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE - i. • -•;.:• ST # INVOICE <br />35 /89.06 41 4 <br />8 6 I 6 6 c2 0 046 `0) /0 -31.'7 SR# 0 0 6-Z4-6 4- <br />C-57 Letter of Authorization to sign perm -&___I__aachment C-57 WC -WAIVER <br />El ID 29-02-001 WEB <br />9/11/2007