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PROPERTY <br />Owner Ani/Y1 r Ko 9 6,) <br />gts ANT .F0 <br />C-57 Contractor 7,..4-e tett. <br />Address P. c . Boy 105449 City TrAc. Zipc15$7 Phone#(IQC9 77 (-) <br />oil <br />Address 22 0 Ah F-45 T .5+. City IA)0-.Okivozip ci57/‘ Lk* 1°21IPlhone# 65!".'.1)(M5 2924 <br />San Joaquin County <br />vcr-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 PpW6Atio-6-Arr,icalIntepmpliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ' <br />A 00 ogel Ha4 i Assessors <br />WELL Location !L/7 L1 /0 , TriA ).c.r) Cross StreetCAPitoL • City L--0,01 Zip 9s2v2 Parcel# C5 43- 1 5 <br />ORIGINAL <br />RE 17SITE <br />UNIT IV <br />APR 1 2 20 05 <br />ENVIRONMENT HEALTf <br />Consultant/ Sub Cntr A rf • Address S3 7 si,14,A../4),. City-57OLK Lic# z 27 phone#te,(0 Y62 - 06 <br /> <br />GIS Coordinates: X Y , Township 3k) Range 5 6._ Section fq <br />WORK TO BE PERFORMED: ...c <br />-44 XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # <br />',RWELL # Nilki- iS pitki- 14 mbv-Is , <br /> <br />la-*Other <br />• <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i -7 • <br />MONITORING a HOLLOW STEM DIA. OF BOREHOLE IV' 0 MULTIPLE CASINGS XMULTI-LEVEL WELL CASING DIA: I. / ' <br />a XTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS k'1e Y A TYPE OF CASING: fl STEEL 0 PVC AOTHER: 4,/, E 74)01 t <br />r] VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ji i TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 'No (NOTE: MAXIMUM FREE-FALL DEPTH I 30') <br />0 SOIL BORING a HAND AUGER . GROUT SPECIFICATIONS i4./ 04 y <br />fl OTHER: )(OTHER SQ A i C._ • ''' - • BORING D BOLTED TRAFFIC BOX or D STOVE PIPE <br />STce I CONDUCTOR C s-4,-.-4 <br />COMMENTS: < 0 AD *IL -1-11: CAS) A5 f i <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 1 ' Ci-y 1,...____ Title/Company AC6Ltf-i /V) A (1//9 G (),--- /9 • C. /--' . <br />i <br />J, C v 1./iAli--- Date eV/ q <br />DEPARTMENT USE ONLY <br />a DESTRUCTION (choose type below) <br />fl OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: ImoRK PIAN A - Dce <br />NG PROPOSED Es (if YES, list specifications in comment section) <br />Print Name 1/.41 t/ 7? <br />led , Zifset' SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Oct <br />Application <br />- <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Final Inspection By <br />Date Issued <br />Date <br /> Area D 6 (C)(,1 <br />/ -er Date <br />Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE - • NVOICE <br />3501 Wil F5.1 2.110?- Gat q I. SR# 0 0 4Inci <br />C-57 V -WAIVER C-57 Letter of Authorization to sign permitEscxachment doc <br /> <br />EHD 29-02-001 <br />6/22/04 <br />