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PROPERTY <br />Owner D C-1 13; f J 01\c, <br />C-57 Contractor OikAO cc <br />Consultant! Sub Cntr <br />GIS Coordinates: X <br />Address gc15 S iMvs-k)n Pt City -re(Ji( Phone# _Of)99 2---7(93V <br />DfI Address S(.6.32,' c, e. City Cfe:AgAC4 ZIP957 LLic# 7/75/ Phone# 5g <br />Address S1 -7 S1-444W R8 City 1/4S To KpALic# a 7 Phone(Z9) Y 61 — Oa (9 <br /> , Township Range E- Section G <br />zIpcIS Zl e <br />Joaquin Lounty <br />Enviroi....iental 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 />LON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDr ,) <br />SITE <br />MITIGATION <br />UNIT IV <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describd1P4apgd4tiorii:Orrkcie4aompliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location .32.3ei . AsSesors <br />Cross Street f+V.:- City 70C.-/(Ofi•t•I FIS Z .-Piarcel# Ohig HE A L 1 II ULPAR <br /> <br />WORK TO BE PERFORMED: <br />'XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />Ar\WELL # M <br />0 Other <br />COMMENTS: SEc_ fiffR4\/QD <br />TYPE OF WELL <br />XMONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />II SOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'AHOLLOVV STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Nees [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS PORTIAND -rifA. .lj <br />0 OTHER APPROX. BORING DEPTH 625 # OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CASING THICKNESS <br />DIA. OF BOREHOLE I° 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: cNi <br />DEPTH OF GROUT SEAL 55 I TREMIE TYPE TO BE USE I: ik-AUGERS 0 HOSE <br />,-t)Q0vIt i-to <br />TYPE OF CASING: 0 STEEL ))1PVC 0 OTHER: <br />CONDUCTOR CASING PROPOSED NM (if YES, list specifications in comment section) <br /> <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 IL 7 Title/Company p80. i_c M /I fv4cv-- ) <br />Print Name —77/Nr) Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3230 No r+1-1 West Lein ,c <br />WORK PLAN DATED: May 9 2 0 0 5 <br /> <br />Application Accepted By Vi cf-or L. McCerfn <br />Grout Inspection By V i L ) )14 pate /—'Z/ - S- Final Inspection By \if o4Yi L, 411 ate3 13(i6 6-- <br />Destruction Inspection By Date <br /> <br />Date Issued 9-zG0 Area /ei:/"51 <br />COMMENTS/CONDITIONS _En S Chl 0-F) IWO i-nooi 4-or: p_ vi/e LS M -4 eind M W -5 <br /> • <br />ACCOUNTING ONLY AID# FAC# , <br />.-f <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE 17,.....SFItILIC-F RFQUEST # INVOICE <br />36-o 7 <br />3..5-o 3 <br />4 99 <br />a 7 / 3 9. o& 228 1.7 3 ,. (/,-SR#017 L. 4 - „.... <br />C-57 WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign perm _aachment doc <br /> <br />EHD 29-02-001 <br />6/22/04 <br /> <br />IA %kJ-3 <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />,Q —ApR,) Z-00 c 46-7 O MA 7