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WORK PLAN DATED: <br />Area Date Issued <br />Final Inspection By Date <br />Application Accepted By .11k <br />Grout Inspection By <br />Destruction Inspection By <br />o6Ev <br />Date <br />Date <br />_n Joacruin Ciounty <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.orgiehd <br />Well Permit Application <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 />WELL Location *OS . Al 1/co.-1 /Uzi <br />7 <br />Assessors <br />Cross Street Akifile4 ied CitySteckA.1 Zip TS Parcel# 3 —C 2 — I 44 <br /> <br />PROPERD' <br />Owner tvt 6 er• r 11,4Ieid Address 77130 Aocity--Ci-, (.4,16.1 Zip 7S2c7-Phone#(4-CO Lie 7. 7- - LZ 77 <br />C-57 Contractor V1)"'vA q Address 32. ¶/l Petal eivAity Ihc- k'< ZipLIY533Ligtp-i-‘"7 Phone#( i'25)52/- /9 9a <br />Consultant / Sub Cntr./ -1:Oci r•( e k co /1 4. Address3`i57-C- V, P1 c' Ality Lic# Phone#(925)ci4f Y-2 L <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT,(EOPROB?) HYDROPUNCH, HAND-AUGER, OTHER*) <br />)(SOIL BORING # 1-39 U WELL # <br />U *Other <br />COMMENTS: <br />fill COPY <br />SITE <br />;MITIGATION <br />UNIT IV <br />DESTRUCTION (choose type below) <br />U OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS C <br />TYPE OF WELL <br />O MONITORING <br />a EXTRACTION <br />[I VAPOR <br />°AIR SPARGE/ OZONE <br />)(SOIL BORING <br />O OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a HOLLOW STEM DIA. OF BOREHOLE 2 a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: fl STEEL fl PVC a OTHER: <br />O MUD ROTARY DEPTH OF GROUT SEAL 0 TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />'PUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U HAND AUGER GROUT SPECIFICATIONS 'e 'L c e•-rit <br />U OTHER APPROX. BORING DEPTH /0 3 o D BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Ordinan9es, Rules ajJ Regulations, and all applicable California State Laws. <br />Signed x i'\,---i_ 74. - e—..2 _____, e-r-X--......_,- Title/Company .R"i4e..://eci• /c- 6-1 /it' .-)11-714-c':--<"'I'c / <br />. . , . <br />Print Name <br /> <br />WA:J7,1 0/5 Date 9 -/ 2 <br />DEPARTMENT USE ONLY <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: L 410s N . (k.1 tsey. (A)a.A/ <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RE 'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />--C1 0 ( 7-} SZ, .8 ti? •), V.4,07 SR# 00 5b 2_1? / <br />C-57 V WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />EH D 29-02-001 <br />6/22/04