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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />600 East Main Street, Stockton, CA 95202-3029 L <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sjciov.ofid <br /> <br />WELL PERMIT APPLICATION <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDti ' <br />itt — Application is hereby made to Sari 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 Well Location 5441'67. w•ivisiz-Lo3 Cross Street 01) ER- ktlsert.. City -51-Octe-ro t•-) Zip 4/5-.9- /5- Parcel # 093' t -S-c)- Property <br />Owner 5 A Ori Address 91- 25- Otittw--kJtt.)z)4E. t\s/ City STar.-4--701--) Zip /Crt:;-(ti; Phone <br />C-57 Contractor 5C3iL-Pri-g3g7 h,-7 C-- Address 2-6-5 ii• 6-0-0-2 57- City I ‘A-LAsIte Lic # 13404.5Phone 55.5-60'71- ?‘tic,c) <br />Consultant/Sub Cntr 5 r)C...- Address 57 1-1 . 51Tit 57- $6-16-4 City -F--itEslio Lic #0S--d6" Phone <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />12:1 NEW WELLJBORING (CPT, OEOPROBO HYDROPUNCH, HAND-AUGER OTHER) 0 DESTRUCTION (CHOOSE TYPE BELOVV) p SOIL BORING#-4/ N3'rlIeri<li S - 0 OVER-BORE DIAMETER 0 wELL # 0 PRESSURE GROUT 0 *OTHER <br />COMMENTS: (9 30$,J-Jks "r7 t.1Wi lEort4A4s Alf .9-4. 2,03-"W-04-.5 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />o HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE/OZONE PUSH PONT YOR CPT) <br />'SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER: <br />ryi Lt_c iC_OZIJ,CTOclirCASINT4)SEuDi scpecificalion mEtiztiip , <br />nr r rocot <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 pplication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable,C for i Laws. <br />Signed Title/Company ---?/to,..frr-T-41-,14i-6,4-4-- ; A-7-77+ amirocc4":4.011 <br />Print Name Date ?a" <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />DEPARTMENT USE ONLY <br />Rev( <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br /> <br /> DATE ISSUED <br />FINAL INSPECTION BY <br />DATE <br /> AREA <br />DATE <br /> <br />COMMENTS/CONDITIONS: 48a46/etatrimi e / -Aes cdorti.pej r/yt t ,411144-d— p#0,rrn dr ms,echey--1, <br />5" I bdit re—t rn- re e-r/ cif\ e <br />ACCOUNTING ONLY: <br />(.1 (I <br />AID# FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # REM:, BY DATE PERMIT/SERVICE # INVOICE <br />240 1- <br />lifOf _c7 Mr. A 1 / 7 y <br />1111111 \ /G In <br />to-2-7 --27),4 <br />-- <br />//9-p ? sR# 544OV Ii33.50 <br />GROUT SPECIFICATIONS <br />COMMENTS: EX ph ry 120 riekiS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0.C. " 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes No (NOSE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONSEer-rioNilt-, c-iti-9j .72-- I <-475* tArtavr a- b"ASINI.44....tc- <br />APPROX. BORING DEPTH de..,15- ; e ' 13 BOLTED TRAFFIC BOX OR EJ STOVE PIPE <br />ftLct-;cy <br />ENCROACHMENT DOc <br />WELL PERMIT APP EHD 29-01 11 /5/07 (WEB)