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I hereby certify <br />County Ordi <br />Signed x <br />Print Name <br />t I have prepared <br />es, Rules and <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 />Assessors <br />WELL Location 364- EA4-1- \A/LI:v.p. A- Ve., Cross Streeto1114 ,•\.0ittL11.1City 0C-14-f-1-5A Zip q5-(;.2/ Parcel#FrA) <br />PROPERTY , TAI <br />Owner N:),A-KI Jatt 4141/Address -3614-./t4. ett klezity -1-,--c81-4-cs-k„ZipilS-aP-Thone# (429)4(0 8 - <br />C-57 Contractor fl 'VP-6 KIS Address 9 9 5koit S ea& City r-oVRAYs'cISZip .cLic#693615"Phone#P4 "1-1).-'3V0 <br />Consultant/Sub Cntr e"Priell liCaeitCS I 99 c ect- ei,kerailk-tsk ) Lic# Phonelt_?‘0 9) <br />GIS Crcerdina46)( 37`57 ) /V )/ , Y -1Z% ci 7' /2,4 , Township Ziti Range 6 <br />WORK TO BE PERFORMED: <br />Section 2 2. a <br />I NEW WELL / BORING (op- EOP • : HYDROPUNCH, HAND-AUGER, OTHER*) g DESTRUCTION (choose type below) <br />I SOIL BORING # fa CA- PPP-6A 0 OVER-BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />I] *Other GROUT SPECIFICATIONS <br />COMMENTS: no )L-- &kJ/Xi< -7(7 f5.)11._ A-Ail) cvzot./A)b,.04-7-74-, 41. 5 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL fl PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS U HOSE <br />0 AIR SPARGE/ OZONEAPUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes <br />SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />OTHER: 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 />,6ø,/o2) ) 113 <br />Date <br />DEPARTMENT USE ONLY <br />3o <br />Date Issued --.5 Area <br />Final Inspection By Date <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />VAPOR <br />INSTALLATION TYPE <br />I HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />13 .MUD ROTARY <br />0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED <br />0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> (if YES, list specifications in comment section) <br />Title/Company <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />- Application Accepted By <br />Grout Inspection By Date <br />Destruction 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 />a I 7 a, 3 53pv 7 sR#03508 y <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04