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Environmental Health Department ORIGIN-kis ITE <br />San Joaquin County <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 GATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org,SECr --m NIT IV <br />Well Permit Application <br />WELL Location j..50sj,LAJ; i 5o v1 Wit) , :)tegroks%irtreet lzon tn)t4/Clity "24-0(-- A Zip 4/5.25 ParcesIstrs //7310 6 / <br />i <br />Address 1.;ittityn-f,.-i•Al i141 City c -T. Z096670 Phone# 5-6Z 5z/ -3s--8 <br />in) Address /0 i k /hk 4vt City /hi A € ivt Zip92 5-Lic# ei1.5-YgPhone# J9 '9 y <br />CL$ -4 JiAddress ?IS I 6-1 iNte Li 51.- 2. 5-5--C.. . Phone# Y 66 <br />Y , Township Range 62 Section 1 <br />WORK TO BE PERFORMED: <br />?ft NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />RWELL # V t,A.; fa 6/ EW '54 U SOIL BORING # <br />U *Other <br /> U OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />DESTRUCTION (choose type below) <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U MONITORING 7(.HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:2 " <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS (._ (-. IC TYPE OF CASING: a STEEL jitPVC a OTHER: <br />'VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ,Z— 2 3/ TREMIE TYPE TO BE USED: XAUGERS a HOSE <br />U AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS re.-v 4{-.---4 Czt- **-----%-t- <br />a OTHER: 0 OTHER 116 tPPROX. BORING DEPTH .5 I '0 AOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED AiC (if YES, list specifications in comment section) <br />COMMENTS: 11.65C, r's Th::-(21:3 aii5d. a e5 I "Th <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 Regul4i64, and all applicable California State Laws. <br />Signed xjil "/4 K:2 Title/Companyfrd ot c.- 1/14-1 6) dilk ./ eV tV71-7 <br />, <br />6Pe.4 65 In; 67,C.IL. <br />Print Name l ei, ci.-c., d 4. t/o, 1 Date 7 - -Z -- 2-CCS <br />DEPARTMENT USE ONLY <br />/26n Aj , leAhek Wor-44 gft--- 6-0)' <br />/ 2.06)(-- , <br /> v/ <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />/ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE # INVOICE <br />Z60 I IV\W - 'Ceti 1013g) Clok 2-1 SR# cog( 1 43 <br />C-57 / WC '-WAIVER C-57 Letter of Authorization to sign per <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 describedFt <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmerilat <br />ItOficN htitikatimpliance with San <br />aJ <br />" <br />C-57 Contractor 1,4.;2 (-k2..v.,A i <br />Consultant / Sub Cntr erec <br />PROPERTY <br />Owner }-+1 CI I Cc <br />S-333 <br />GIS Coordinates: X <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />54, Date Issued Area 0681 <br />'a P-1 5 Date Final Inspection By 'Die / -0 <br />END 29-02-001 <br />6/22/04