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SITE MAP IN UNIT IV FILE, ADDIRESS:4 <br />WORK PLAN DATED: 3[15 to—) <br />DEPARTMENT USE ONLY <br />3a ?- t,t) OtalLbs <br />18 ?IS Aire/20_.- <br />Date r <br />Date Issued 7 <br />Final Inspection By Al <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date 1 >e) <br />Date <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 />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is riviiMillToliict*PeAkfithiltlENT <br />Section <br />WORK TO BE PERFORMED: <br />XIEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br />O SOIL BORING #fl OVER-BORE. DIAMETER <br />WELL # 3 D PRESSURE GROUT <br />o *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />SITE <br />MITIGATION <br />2005A7dvpm 2 23 <br />SAN JOP,OUII COUNTY <br />ENVIRONMENTAL <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />A Assessors WELL Location 3012 Cask- taokt- (oc ?-_ck Cross StreetCipittev1/4.qc4e. Avictity ,S1-ve--1-1-0k,k Zip 9.5zozt Parcel# <br />PROPERTY <br />Owner Atki ;c31--pr- (4.05-vvviviEZ.. Address 9ts07 a.,0 Ott"( Cr•te Ic City 5.6&61.--1 Zip 452-1q Phone# 7 7--Lfgi) 2- <br />C-57 Contractor (:(1.TCte1e Address 3(L U( brae- CityAitiity fricvgip ri.1113c# 7/ 15/D Phone# 0106 30 .1149 <br />Consultant/Sub Cntr Adikl.VCerk eleCgt0.1 10:4“46114-ess cb'Si SitetAni CA City qtek-,Irvi Lic# &3D22-7 phone# 4E67 --/004, <br />GIS Coordinates: X , Y , Township Range <br />TYPE OF WELL <br />.*ONITORING <br />O EXTRACTION <br />O VAPOR <br />AIR SPARGE/ OZONE <br />O SOIL BORING <br />O OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE e a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 221 <br />CASING THICKNESS '-ID TYPE OF CASING: U STEEL r.,VC U OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: XAUGERS U HOSE <br />p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 111.Yes U No (rTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />HAND AUGER GROUT SPECIFICATIONS <br />OTHER APPROX. BORING DEPTH /0 OLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED f'‘• (if YES, list specifications in comment section) <br />INSTALLATION TYPE <br />NiHOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />a 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 />Signed x Title/Company Sielft gedc 4 /Adwatteel t t) e:Ku <br />Date 7/1 VD Print Name c <br /> L <br />ACCOUNTING ONLY: AID# FAC# <br />— <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE z QUEST # INVOICE <br />111 1 '' S RW-1 30 ? , <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br />EHD 29-02-001 <br />6/22/04