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tLe —91-k51(Ao-0- mvanc eci Title/Company (cEnvwinne -I-d, Ii L <br />Date 11 Derenth.er• Obo <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (.3 4/-* /2-- <br />WORK PLAN DATED: <br />Signed x <br />Print Name 'RObl,Y--V t-7,NACrfAkk <br />35.4 f\D <br />Date Issued ,EirED Area <br />Final Inspection By Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />San Joaquin County nEcnive&R IGINA <br />Environmental Health Departmentu SITE <br />600 E. Main Street, Stockton, CA 95202-3029 uct; 1 9 2007 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV ENVIRONMENT HEALTH Well Permit Application PERMIT/SERVICEt <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 13229 Wesi 1.2 Cross Street Mtn:SOCK Rd City Locit Zip CIS.:)(1:) Parcel# C.9)0 - cS - <br />PROPERTY , <br />Owner 0,11(We S with Address 1 3nti tunt I.4Lcf 12 City I cdi Zip ctsq Phone# OC9- Nck-,(./ is- <br />C-57 Contractor IvionPAi affiEntaboiMitted Address. ?)-1 Ihaw "Rd _ City Ntaltyn Zip1SQ1S- Lic#05//):221 Phone# DOM 4.160- Ibta, <br />Consultant / Sub Cntr Mutway1 (1/4-11thentnenia Address W:31 3hcau gd City '44t0A-tyr1 Lic# (.01(;;)2 -1 Phone# -1-10 -1-10b(z) <br />GIS Coordinates: X 3s" •114) , y -121 W35 , Township Range Section <br />WORK TO BE PERFORMED: <br />14NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />2SOIL BORING # B9 C1n4 911 I- sv.5- a OVER-BORE. DIAMETER <br />a WELL # a PRESSURE GROUT <br />U *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />r-v i-• TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -4- <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE 1,25 a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />O VAPOR a MUD ROTARY DEPTH OF GROUT SEALLetc10 t TREMIE TYPE TO BE USED: a AUGERS a HOSE --4... <br />O AIR SPARGE/ OZONE jr-PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Ti.kb.e_ 1/11 "p6r-1-ACIvici 0 e WI en+ <br />a OTHER: a OTHER APPROX. BORING DEPTH 44 i-i.7.t 10' bst a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED no (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 Ordinance ules and Regul ions, and all applicable California State Laws. <br />ACCOUNTING ONLY: AID# 1 FAC# <br />PE CODES FEE INFO AMOUNT REMITTED 044 41 REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />ff9 <br />.„01amr5""*Cti,* /z)rdc7 5VO.532.e# , <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment Encroachment docAifri <br />-CY-) <br />oQ <br />—Q <br />EHD 29-02-001web <br />6/22/04