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(A <br /> <br />TE <br />4 PR 1 .1 )4N1 <br />EN VI 4°08 ?OP& <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PER/14 1:11111-ig I r/SER n 1.1-8 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is npince 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 J 5-G34 I -Roct.e Cross Street LOnc.-"Ti•e.-c- 1..City Es cck,i Zip ct532ei Parcel* 7 7 el -I zo-otf <br />PROPERTY <br />Owner.411)cy +-klowde. 1if/4/5tf,21 Address / 5-6.3`1 11A-rt A City 65 te'll Zip 5"..3 20 Phone* <br />C-57 ContractorGfc3 --Dvv-,v Address 15-0 )40.e c3 F,1 City f ! 6/14,rt:rxz_ Zip"/L/S-5-3 Lic#4,9407-Phone* 3 "77-5- 3 /3 -5800 <br />Consultant/Sub Cntr /),TC_ A 55o c:texte.5 Address (1(1 L oi City Ill cectLic# Phone* Zo ci <br />GIS Coordinates: X , Y <br /> <br />, Township Range Section <br />San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />4.0,1 ON '11 1 <br />WORK TO BE PERFORMED: <br />XNEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />D VVELL # <br />D *Other <br />COMMENTS: <br />Co CPT <br />U DESTRUCTION (choose type below) <br />U OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />INSTALLATION TYPE <br />fl HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />El MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Z1 a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: _I\JIt <br />CASING THICKNESS N Pc TYPE OF CASING: a STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL I 30 TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> <br />XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes El No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />El HAND AUGER GROUT SPECIFICATIONS AierAl—C,e(4'%-e <br />OTHER APPROX. BORING DEPTH I 30' fl BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 />Print Name Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 113/0 <br />Application Accepted By <br />Grout Inspection By Date "I 12.11tro- Final Inspection By <br />Date Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAG* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />35-10 3 Al ei4,cio a tf(ztioc SR#00 S 3 1 -473-2..) <br />TYPE OF WELL <br />U MONITORING <br />U EXTRACTION <br />U VAPOR <br />AIR SPARGE/ OZONE <br />XSOIL BORING <br />OTHER: <br />Signed x Title/Company ( 1/VIA LActy-ir Assoc:I .-1-es <br />'t Date Of pc,2_10X <br />DEPARTMENT USE ONLY <br />5-6 3.'( 51-(44Aist.---el <br />: Liti %/OS Date Issued <br />AAA <br />Area <br />Date Date <br />C-57 Letter of Authorization to sign permit C-57 WC -WAIVER <br />EHD 29-02-001 WEB <br />9/11/2007