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0 i FILE COPY <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> hd UNIT IV/(209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd O <br /> L%,=a Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <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 9.111115.n3�a(nd the Standards of San Joaquin County Environmental Health Department.Assesso"qn}�� c// <br /> {% (� /1&6 _Cross Street GtR ar City 5� n Zi `)510} Parcel#r�! r/D� <br /> WELL Location_T P <br /> f No y 46 5:d'e') <br /> PROPERTY or 1 <br /> Owner ti-ccolY1 Ceoo,34f' Address City .IZip -e Phone# <br /> C-57 Contractor K5Z nVr, in Address ZD b. tas -or-e-J City Oo1'w.d,Zip 9S?%Lldt Phonee#AioWIPTr1r+ <br /> Consultant/Sub CntrLFP' AddresAlID PBWLI( SI' City m :II Lim Phone#t41S)6f3-'IS-60 <br /> 14% Fioo� <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCFF�f,,HAN UGER,OT R') n DESTRUCTION (choose type below) <br /> (]SOIL BORING# I . •N! _ ALS 5� ��ZJ a I]OVER-BORE. DIAMETER <br /> �QWELL# 1 aPRESSURE GROUT <br /> n•Other�1 GROUT SPECIFICATIONS <br /> COMMENTS: Won�- Y-o 'Iv.–c- -pLAtLf i XhoN s o r P/A D Ate. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u MONITORING HOLLOW STEM DIA.OF BOREHOLE6 4.950 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: 2^D r <br /> n EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL XPVC n OTHER: <br /> u VAPOR n MUD ROTARY DEPTH OF GROUT SEAL-I 3,041 TREMIE TYPE TO BE USED: gAUGERS HOSE <br /> AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER: 40THER Soot III APPROX.BORING DEPTH 65.0 EXI 'K BOL ED TRAFFIC BOX or g STOVE PIPE <br /> 1 f^ <br /> CONDUCTOR CASING PROPOSED IV , (If YES,list specifications in comment sedlon) <br /> COMMENTS: Wel15 dD f/L USPa Lor rQlr SD Ar4�l, + I )on D rAolts <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cerNy that I have propel d this application and that the work will be done in accordance with San Joaquin <br /> County Or antes,Rules and gulations,and all applicable California State Laws. <br /> Signed T ( on'S�0e/Company o' t'j (, Pk <br /> Print Name � aSo ri0�0 Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Qti t f�+t�0 <br /> WORK PLAN DATED: .70 <br /> Application Accepted By Date Issued— <br /> Grout Inspection ByDate Final Inspection By '9alB� <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNTRE��M991TTED CHECKp# RECD BY DATE "PERMIT I SERVICE REQUEST# INVOICE <br /> loot 968 SR# y3/� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dot <br /> EHD 29-02-001 <br /> 6/22/04 <br />