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WELL Location q3 3 WI c CO 445 Assessors, „ <br />Cross Street Li ntiA 51Z City S NI Zip 9.(249 Parcel# /1-7-04D - <br />Section GIS Coordinates: X , Y Township Range <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit Encroachment doc <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />MITI 'èN <br />JUL 1 3I IV IV <br />ENVIRONMENT HEALTH <br />RVICES PERMIT/SE <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 />PROPERTY <br />Owner flA019) 61( -149 Pyri144*Add ress I DS WSW011.54-- 14-- 4 City p ,r3ynori4 zip342aPhone# (25-)447 -/?04 <br />C-57 Contractor eitp.e.fri Address 9co 1--Ae,weI2 d CitYNOrfrre2zip943-cs'Lip#.6.541107ione# (405)3/3—.6-600 <br />Consultant/Sub Cntr 1st/A4u...4 4icortv Address Og 7 Shwa) 2d City 517044 Lic#6g0022-7 Phone# 9)4 (07 -10 Of° <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />SOIL BORING # C PT a OVER-BORE. DIAMETER a ELL # <br />*Other <br />COMMENTS: <br />TYPE OF WELL <br />I] MONITORING <br />a EXTRACTION <br />fl VAPOR <br />.0 AIR SPARGE/ OZONE <br />1NOIL BORING <br />OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 ir ° MULTIPLE CASINGS fi MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS ki I TYPE OF CASING: a STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL so VI TREMIE TYPE TO BE USED: El AUGERS U HOSE <br />USH POINT (GP or CPT)GROUT SEAL PUMPED: A-es U No (NIOTE: MAXI UM FREE-FALL DEPTH IS 30') <br />U HAND AUGER GROUT SPECIFICATIONS fonflocfre beA-175 <br />U OTHER APPROX. BORING DEPTH /00 ( a BOLT D TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED A (if YES, list specifications in comment section) <br />INSTALLATION TYPE <br />D HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />El MUD ROTARY <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 />1.0iniet 1.(et ylk loae \ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDIrt4S):433 3c-'b, <br />WORK PLAN DATED: 1-4 <br />Print Name <br />Act uoiA.Ltet 6reAti1) <br />Date q0S- <br />COMMENTS / CONDITIONS. <br />ACCOUNTING ONLY: AID# FAC# 5R CO 13 1)7 1 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE ERVICE REQUE * *ICE <br />35° \ --6ct, 3 2.s 3(01 $ 3 (.9' 2..214.5 7/4 SR# 4N,„--7 1 <br />Signed x Title/Company <br />Area <br />Final Inspection By /1/1 r 0 Date <br />71t3 /6 5 Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br />REC <br />B PRESSURE GROUT <br />GROUT SPECIFICATIONS