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INSTALLATION TYPE <br />I HOLLOW STEM <br />El AIR HAMMER/DRIVEN <br />yup ROTARY DEPTH OF GROUT SEAL <br />OZONEXPUSH POINT (GP or CPT)GROUT SEAL PUMPED: ['Yes <br />0 HAND AUGER <br />O OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br />TREMIE TYPE TO BE USED: fl AUGERS 0 HOSE <br />1:1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />t I have prepared I hereby certify <br />1 <br />County Ordi es, Rules and <br />Signed x <br />Print Name letp <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 />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 364- aiv-A AcIQ, Cross Street (.1-1.1 ,04tc141.1City ‘...4.-(2C-14-17.5-1‘ Zip 445-1?1" Parcel# A-11-W---11LIN Nit, <br />Assessors felew <br />PROPERTY , <br />Owner ,./:}41/4-1 JOT' CP 4. it—I/Address -36144-C&I keeity (-11113X-ZiplS-ab .Phone# (1129) 144)5 <br />tIert•\ <br />C-57 Contractor '---QP--(ttl KIS Address 9 9 56.4 S qielet City 9 V(2-0SctS Lic#68396‘Phone$624 1-73.--3110 <br />Consultant! Sub Cntr 8.psieft, 2recaiscs 189 cRh k Wecfeikktrtit) Lic# Phone#9,) <br />, GIS C ordinates": 'X 4 3 /T ) ,Y ci7 iZ , Township ZAJ Range 6 Section 02 2, <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (cjo-r CE0P <br />I SOIL BORING # 6 64-p pp.& <br />El WELL # <br />El "Other <br />COMMENTS: nr Boe_JAX-7(7 iicr /1/04 C1iZotiAzug47-&P <br />SITE <br />MITIGATION <br />UNIT IV <br />HYDROPUNCH, HAND-AUGER, OTHER") ['DESTRUCTION (choose type below) <br />['OVER-BORE. DIAMETER <br />['PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />O MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />1:IA1R SPARGE/ <br />SOIL BORING <br />O OTHER: <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />application and that the work will be done in accordance with San Joaquin <br />ons, and all applicable California State Laws <br />Title/Company 6A)40k-6/2ji /er---/1 ) /A) <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 30 Li <br />WORK PLAN PLAN DATED: Aii6 <br />Application Accepted By <br />Grout Inspection Inspection By Date <br />Destruction Inspection By Date <br />Date ____7/2-yo <br /> Date Issued ..-5/-q/0 Area 4gy <br />Final Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # ' REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />0 t 7 3 5 3/.207 sR#co sow? <br />C-57 <br />WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04