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<br />'AEC E <br /> <br /> <br />ORIGINAL <br /> <br />JUN 1 6 2008 San Joaquin County <br />Environmental Health Department <br />ENV1R ON flal Lgtitattii Street, Stockton, CA 95202-3029 <br />PEINI;TI$Miginax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 1500 &law "Kiocta Cross Street Tft.fulaprit City 5-fcC..k.+On Zip SZ S Parcel# q 52 Co 00 <br />PROPERTY <br />Owner Con/..faSS Gmotir USR Address 2900 Cio r Icm orii City bliztl:ct.... Zip aUR Phone# i-04 -5Z8 - 1582. <br />C-57 contractor Co...XaCke. -1)katn. Address -5(.0-5a otAtc.,6,rda city e- ontlioVa-Zip95}12 Lic# 919.5/0Phone# 914? - /1(4 <br />Consultant / Subntrik.VID. 0..0Vrtirli-S Address cicoci -ve INOSVirl /114.4t_i)r. City Lic# Phone# S12- 3412-9qq/ i <br />Suric. 116 <br />GIS Coordinates A7. 93-s",Qc( Y 0-12.1. -2.1483(0 Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />I SOIL BORING # IS1?) -13 0 OVER-BORE. DIAMETER <br />IWELL# kylu).-1,101 a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ ft <br />I MONITORING I HOLLOW STEM DIA. OF BOREHOLE fe a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: .-,, <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS iit) TYPE OF CASING: a STEEL iii PVC a OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL to TREMIE TYPE TO BE USED: I AUGERS a HOSE <br />fl AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />I SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />I] OTHER: a OTHER APPROX. BORING DEPTH -O' ''' tr 5 ' I 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 ftepulations, and all applicable California State Laws. <br />Signed x tui 4, .0, 1./4- Title/ComE(npa.in)yr Consu 1-1-0-Ke / SQ14-arri- <br />Print Name EriC rnothi kelen <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE : CE REQUEST INVOICE <br />6.-fi.40) y L "0 • 1041124PR— GI 4-1•.Fc sR4f9051/5 7 7 <br />C-57 1 WC ••/ -WAIVER C-57 Letter of Authorization to sign permit doc <br />EHD 29-02-001 WEB <br />9/11/2007 <br /> <br />DEPARTMENT USE ONLY <br />/500 "/SareAk. b <br /> <br />Date <br />Date <br /> <br />Date Issued <br />Final Inspection B <br /> <br />Date (e /770,1