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nVED an Joaquin County <br />Environmental Health Deparinire <br />600 East Main Street, Stockton, CA 95202-3tat A 2 2-008 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.oreliptdmi- <br />cl\I\PAUONIL"' " Well Permit Application pER9,1,T, !SUNG <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <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 />seslsitors 2,51057 <br />WELL Location I 6 $ocan Si/Q_Et Cross Street 9-a-k-bil AV , City i'POn Zip 95366 <br />fzr <br /> <br />Owner <br />rERTY <br />L ( <br />-ri otain <br />(kW , I I)i" AclIress 3):7 131.6 I/1 0/1, City K ., f)y\ Zip 1M) Phone# <br />C-57 Contractor 1 NAiq ktk'I's 5t,0 fity 1%,VV,Lt 1514L 7 0 @(1(Dione# 9 1 2S <br />Consultant/Sub Cntr A T Ccc A . „O(.16 ,Qc i(1_( Address lir? L i cWc2j)ityl M0161-0 Licit Phone# 571-P-21 <br />GIS Coordinates: X Range g E Township Section <br />WORK TO BE PERFORMED: <br />NEW WELL I BORING (CFI GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />k SOIL BORING # <br />a VVELL # <br />a *Other <br />a DESTRUCTION (choose type below) <br />U OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2.11\ 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: ' , <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS N 1 ./\- TYPE OF CASING: a STEEL a PVC ill OTHER: ki A r <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5-s Q ‘2 1( TREMIE TYPE TO BE USED: a AUGERS 0 HOSE ' <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes g No (MOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />!SOIL BORING a HAND AUGER GROUT SPECIFICATIONS IV (gl.k C i vi i? V1)-- <br />0 OTHER: II OTHER 1\1 I APPROX. BORING DEPTH CQQ3, a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED IV .,) (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x W-7 Title/Company 5 6-eutlf 4 Tr Aso( ,-/o-d 1((_ <br />Print Name pek r g_no 61(0V\ Date I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ID 4, Se CA ea S+reef Ri p 0 n. <br />WORK PLAN DATED: eyyl. be.r- rj, ca-0 0 r7 <br />Application Accepted By i chi) r 1 of e. e-4 r <br />Grout Inspection By Nice_4-D e tiValrirt dr Date 3 <br />Destruction Inspection By Date <br /> <br />Date Issued ta " 14 - 0 0 Area /4 q <br /> <br />.2 I —0 Final Inspection By*thrPa riitearin Date 3-11—o g <br /> <br />COMMENTS/CONDITIONS If/ IS +all a+ ; 0 4-1 0F o -Fern r 4 r So is ) VC/ poir pr-ob es <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE EQUEST # INVOICE <br />350 / <br />3y03 <br />41 81,po <br />0 .2,9 4/-,a0 <br />0 383.0o 175+ ,...071 <br />\ <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001 WEB <br />9/11/2007