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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />WORK PLAN DATED: <br />Date Issued <br />Date Final Inspection By <br />Date <br />COMMENTS / CONDITIONS* <br />Al D# FAC# ACCOUNTING ONLY: <br />DATE REC'D BY PE CODES FEE INFO AMOUNT REMITTED CHECK # PERMIT / SERVICE REQUEST # <br />r S R# <br />.t Vincroachment doc 725/97 <br />S(2\06549 (1 3 ) w oa- /60/ <br />1Plio I 3F.3. 6 <br />C-57 Letter of Author' C-57 / WC.x WAIVER <br />[1-1D 29-02-00 I <br />6/22/04 <br />',6•91 <br />INVOICE <br />PAYMENT <br />RECEIVED San Joaquin County <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 952611- 2 4 2008 <br />Environmental Health Department <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sigov,ojeull/CINQUIN COUNTY <br />ENVIRONMENTAL Well Permit Application HEALTH DEPARTMENT •e/e.", <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 />214 C4L .-r, , -(-1 Assessors <br />WELL Location " Cross Street F;‘1° City ...RX-K-1-0 Zip —I -°""1 Parcel# Ca$ r2c-D14`1 <br />PROPERTY <br />Owner -('-ry orS1.0 t-4 Address "( . EL Potekvb City 4irOCAtrrlOts..1 Zipc:1S2e)ePhone# 20/ 937- 634/9 <br />City 9-11X-K-IONIZip4150 Lic# .3531 Phone* (20:1) Address tX2C 11,1161W:14-i <br />r4k1,t ELO <br />Address 5.ey 211::)4g. 1/3•1 P c# 5-71 7 Phone# g Consultant / Sub CntrEaTTHII-i- E4(, Address City Li <br />GIS Coordinates X 37-7'7q , Y , Township Range Section <br />'ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />C-57 Contractor Frtc.isloi•J <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING a SOIL BORING # <br />AWELL # N'.\ <br />U *Other <br />COMMENTS: <br />fl DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />I 5 a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />r-1,06.44)ca 5 • 32; <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />TYPE OF WELL <br />XMONITORING <br />0 EXTRACTION <br />1:1 VAPOR <br />O AIR SPARGE/ <br />0 SOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />XHOLLOW STEM DIA. OF BOREHOLE 8 a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />O AIR HAMMER/DRIVEN CASING THICKNESSC4 LI 0 TYPE OF CASING: a STEEL APVC ['OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL 2 C•C2 -It TREMIE TYPE TO BE USED: a AUGERS AtIOSE <br />OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ,Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />2.1-i lb .54,61e, O HAND AUGER GROUT SPECIFICATIONS 5' -ro to,41.- 14 t) ffere. €3 OF <br />0 OTHER APPROX. BORING DEPTH SO -Pt AOLTED TRAFFIC BOX or 0 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 />Title/Company 11 it .-414.5 /4/6.-Wle—/° 7;144 <br />Date <br />AVN-- <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Signed x <br />Print Name / 4 C-rt A6-4_ 14 c <br />DEPARTMENT USE ONLY <br />47 . C j4A&49()