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WORK TO BE PERFORMED: <br />NEW WELL I BORING (CP EOP HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />I SOIL BORING # 6(1-4 D OVER-BORE. DIAMETER <br /> <br />WELL # fl PRESSURE GROUT <br /> <br />0 *Other GROUT SPECIFICATIONS <br />g <br />PPP-1)A <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 304- aftth. 4,11e.p. 1./ Cross Street 6111,1 '01‘,V-1/.1City ‘-.:4--0C-14-1-4,-* Zip 4)5-04)1' Parcel# <br />Owner ‘DAki Jat 1.-14, 410141/Address -361 ft -4 Well 4 kleeity -1-7,e--11---611,Zip-Thone# (9479) 4(.08 - t <br />PROPE5TY , 1 <br />C-57 Contractor '01?-(.111.1S Address 2)99 3ketiiSTIcia. City 11(2-kt Zip95:2, Lic#6/34‘Phon4,24 1-1 -3510 f."‘ <br />Consultant/Sub Cntr et2cti.r.L. e--PrItill hle6scs t 99 c i2.44-A1, Wesf e-ikletrtink-10f) Licit Phoneit.?‘09) A3 44—.0 i B <br />GS Criglattfge:k 57'57 i i / ,Y '121 c / 7' 12,') , Township Z A) Range 6 Section 22 ? <br />COMMENTS: no /1---1.30 0- I /X-7‹ --6.L.1--1CT f501 1411 C 1?4:2c1A.:b L.4 477-47 Kt f <br />WELL Location <br />TA' <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL a PVC El OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />El Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify t I have prepared <br />County Ordi es, Rules and <br />Signed x <br />Print Name Date _3/2,--2/0 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 30 44 E— <br />WORK <br />- <br />WORK PLAN DATED: 11116 <br />Application Accepted By --771 -e-rk--1" Date Issued <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />D VAPOR <br />0 AIR SPARGE/ OZONEXPUSH POINT (GP or CPT)GROUT SEAL PUMPED: <br />SOIL BORING El HAND AUGER <br />['OTHER: 0 OTHER <br />INSTALLATION TYPE <br />I HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />MUD ROTARY <br />'application and that the work will be done in accordance with San Joaquin <br />'ons, and all applicable California State Laws <br /> Title/CompanyAA', 60, 6,t)40._b.0.,-11 <br />--1 <br />Area <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />0 i a 3 5 3 (7 sR#Q3 (7).//y <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04