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FILE COPY <br />San Joaquin County <br />Environmental Health Department <br />-(1 600 E. Main Sheet, Stockton, CA 95202-3029 <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 />Assessors <br />WELL Location 19/() konOly Cross Street 61/24/00d 9-city 6-1-ock1bn Zip 2.2.04,-4 9 Parcel# it/"J6 <br />PROPERTY „ <br />Owner CoMelfrblo rrieticetti.Address <br /> <br /> Zip 951J (74.Ph one* ao9 <br /> <br />C-57 Contractor ecr9e:/),,r1 Address ZAOA/ '.96")' $-1- City Aicodbk-kip 95.77gictA Phone* $30 -66 ar-c 1/4„15/ <br />Consultant/Sub Cntr cGt-0 4-A 10, GiGli Address 3/.3‘A.4 Fe2,%•P/e. kt City yloY1Lic# Phone* <br />,, ,„ ,)17 90,Ael .-, <br />Al/ <br /> Pf Vair „. ,_., <br />GIS Coordinates. X 37°5/3" 3,11//, Y LI /0 /0 I X/ W, Township o4 /V Range Section ? 5 <br />WORK TO BE PERFORMED: <br />XIEW WELL / BORING (CPT, GEOPROSE YDROPUNCH, HAND-AUGER, OTHER*) fl DESTRUCTION (choose type below) <br />ErSOIL BORING If 42. U OVER-BORE. DIAMETER <br />a WELL # I] PRESSURE GROUT <br />1:1 *Other GROUT SPECIFICATIONS <br />COMMENTS: _2 SO3'1 626,715 "lb he g -I 11- e -2 ; AA, /12er1724,11'enr h'// <br />SITE <br />MITIGATION <br />UNIT IV <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE, i ' 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />U AIR SPARGE/ OZONE dtePUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />OIL BORI G 1:1 HAND AUGER GROUT SPECIFICATIONS <br />-KOTHER: El OTHER APPROX. BORING DEPTH 1:1 BOLTED TRAFFIC BOX or II STOVE PIPE <br />6-1,11 501P7) CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: P;reC4,42‘4,7 4,9,./ /16 ri h, 1'4. i-c, /C, i t" 10 I ; 6" »214_001 Gt/41-62.4 6.4a A..2„._ A e ,e P <br />t. r, col„ ep re C(4 v No laer'n,, 40,14- 'Gr/e7/.57 <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 Ordinances Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name 171,C Date <br />DEPARTMENT USE ONLY 29- So <br />SITE MAP IN UNIT IV FILE, ADDRESS: •2'02-P? N.a/c-6<n-t- <br />WORK PLAN DATED: t&4 i 7 <br />Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Date Issued Area 06 F <br />Date •17(1 1.,/0-'V Final Inspection B Date ( L( <br />Date <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT/SERVICE REQUEST* INVOICE <br />ROfi 0 S'Iff' 1..- 150 etai sR# 0,051191- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001web <br />6'221)4 <br /> <br />FILE COPY