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Township Range Section <br />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 />SITE <br />MITIGATION <br />UNIT IV <br />2005 APR -5 PM II: 35 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IWIIM)J0,%U'UlitCOUNTY <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Envirot 161 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work descr ari gin compliance with San <br />Assessors <br /> Zip Parcel# <br />(1 <br />WELL Locatio6-- Arkk --faA0 Street 67-3 2 .7.1),,i? IZ• <br /> <br />PROPEW <br />Owner LI C <br />C-57 Contractor <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />A I <br />Address:251 s City Oif Zipq)€3ePhone# 210 <br />Phone# <br />Address City Zip Lic# Phone# <br /> Address 73 7 C 1Yegt.Y 71.1CC'Z'kcit <br />WORK TO BE PERFORMED: <br />W WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-BORE. DIAMETER <br />VELL # fl PRESSURE GROUT <br />I] *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />"[XONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />fl OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPC_IFICATONS <br />.Arq-OLLOW STEM DIA. OF BOREHOLEIM6T1ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />0 AIR HAMMER/DRIVEN CASING THICKNESS i‘j' A- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL /-5- t::-:ae-+- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />a PUSH POINT (GP or OPT) GROUT SEAL PUMPED: a Yes elo, (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER APPROX. BORING DEPTH 7 " f--22e---(---zeliBOLTED 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 accordancq with San Joaquin <br />County Ordinan s, Rules a d Res,lations, and all applicable California State Lar. . <br />e <br />" j')(-9E-7 Signed x te,) 1(&. oaVil Title/Company 6.1.,'-- /./__,.6, 5---i <._•( / <br />Date Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 93 2-- P-Cazje <br />WORK PLAN DATED: <br /> <br />/ /V)L\ii (1/ <br />Application Accepted 13/V jr, fqr ia 1.. i MG eztri-rze, Date Issued <br />Date 4/...7/0S— Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS! CONDITIONS: In &1 11a <br />Grout Inspection By'{f,tr44.4.48-(1/4/41 <br />Fri! 26 0 5 Area 145q <br />te <br />tri --14)e Fro r2f4 Rd. "L'io n o-P two hinni-1-nr;rt wells 6C <br />ACCOUNTING ONLY: 1 AID# FAC# _ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # _ NVOICE <br />3 5-0 i 0 0• 673 tr Z jg.7 -L:4 ( c,....___SR# 00 4 / 823 ) <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Enciirrritoc <br />EHD 29-02-001 <br />6/22/04