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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <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 />WELL Location 2_I G /14 CA I j-Pcfn i-ot Cross Street h''1/4 A rl G ( City 571\c-tetbel Zip 9 544-.L- Parcel# Lii -z-..u- ,-6, <br />,..,, Assessors __,,, ,..,,,., ,., / <br />PROPERTY 1 RCci#V4lartssii 7- Peer- <br />Owner CI- t7 de-5- re'cli re' rl Address 14 z5 /v. El Dcrk.do City 57-oc-Lcfetel Zip 6/.520 -Z-Phone# .061)Ci 3 7-7541 7 <br />C-57 Contractor Pi 5 c. I, Dr, il. fi, Address 511 5h -e(.i3 PIA c Z.- CityVglicr 3,4 01 43.52.54..ic#63g66Phon401)7 TZ-35.72 <br />Consultant/Sub Cntr Co ,,,I c r CA i Tikl., ctv 1 #101216rgs I g9 rfa. tal.1 We irCf .6 rditly- -54-w-trro Lic# Phone# 23q^ 05,8 <br />SITE <br />MITIGATION <br />UNIT IV <br />WC -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 C-57 Letter of Authorization to sign permit <br />GIS Coordinates: X , Y , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br /> <br />El NEW WELL / (CPT,EOPfr7—"DtOBEHYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br /> <br />SOIL B # _5 a OVER-BORE. DIAMETER <br />U WELL # I] PRESSURE GROUT <br /> <br />ii*Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2- in a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />U AIR SPARGE/ OZONE USH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />AcSOIL BORING a HAND AUGER GROUT SPECIFICATIONS rie....c r c e en-e-es 1- <br />a OTHER: a OTHER APPROX. BORING DEPTH SO -('r- a BOLTED TRAFFIC BOX or i] STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: (CIA 7 (Ai I 4-•.1 wn <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 Re lations, and all applicable California State Laws. <br />Signed x Title/Company CO dc-r- 0103/C51-etc <br />Print Name Oil) Loot, Date 7/6 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2.1i, t1/4.) • CO.A.A--6 \ NA- C- S4 - <br />WORK PLAN DATED: <br />Application Accepted By 14-ZrtAA.A._rts-k. ',— <br />Grout Inspection By IA <br />Destruction Inspection By <br /> <br />Date Date Issued <br />Final Inspection By <br /> <br />2-`11 ,Fr" <br />'1/4"jet.A.A"r <br /> <br />Area <br /> <br />Date 7- <br /> <br />Date z.1 9 oss- <br /> <br />Date <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />3 5-0 3 <br />3 5-0 ( <br />--4 Vitf-00 03-t /6- I (Ai 1 I ,..t to & SR#