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TYPE OF WELL <br />El MONITORING <br />EXTRACTION <br />a VAPOR <br />AIR SPARGE/ OZONE <br />16OIL BORING <br />0 OTHER: <br />INSTALLATION TYPE <br />U HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />MUD ROTARY <br />USH POINT (GP or <br />HAND AUGER <br />OTHER <br /> Final Inspection By <br />Date <br />Date <br />vo6u6 <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 />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <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 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 />lkOtAl ., _._, „Assessors <br />WELL Location '3 3 3 nif (Atic, ‘.--T - Cross Street f; f -'1 City 97.01-'' Zip 4-75e-a9 Parcel# <br />PROPERTY <br />Owner t--4 bi5iatillekddress 315 0• 6213vxdo City STY-1j Zip Phone# 93,7- F58>1 I7. <br />C-57 Contractor 464 4... hif5/7.0 Address g.0 filllie 16/1-0 Cityfil01/6Zzip /45.r.luatt 4"5-1014°71Dhone# /Z-5- 3i 3 seav <br />s->itz slargol 2 - I 19 ECOnsultant) Sub Cntr(-02/7H/(-4.• IC4/410 , Address 1-4.--A--/ City A t Lic# 5 7707 Phone# gil 72 9 ...S7H <br />GIS Coordinates: X , Y , Township Range Section <br />RK TO BE PERFORMED: <br /> <br />NEW WELL / BORING <br />SOIL BORING # <br />tI,NA/ELL # <br />*Other <br />(flDESTRUCTION (choose type below) <br />Li OVER-BORE. DIAMETER <br />Ja PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />113 Z .3 3, ej,,Coe 474/ e 67.‘fr <br />CONSTRUCTION SPECIFICATIONS 1\) <br />DIA. OF BOREHOLE Z " a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: LA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: cyt <br />DEPTH OF GROUT SEAL rv" DEP 7/4 TREMIE TYPE TO BE USED: a AUGERS U HOSE cyl <br />GROUT SEAL PUMPED: kes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS.Cro /d9a./ fri?O t9E-2 '/q/6. -C" 4c-/z E-Arr <br />APPROX. BORING DEPTH 9.0/ LI BOLTED TRAFFIC BOX or a STOVE PIPE <br />COMMENTS: <br />GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />r <br />AN fr-ftreICA, <br />COMMENTS: <br />CONDUCTOR CASING PROPOSED <br />n-e)001Veg--9 CPT" 4` 2 /11/47H /A) <br />(if YES, list specifications in comment section) <br />L. <br /> <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, ules an Regulations, and all applicable California State Laws. <br />Signed x "fr../ Title/Company G/7 <br />Date — <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: t5 CaLf <br />WORK PLAN DATED: <br />N trA.- <br /> <br />Print Name 7/e- 6 t c <br />Application Accepted Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />Area Ekk <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P • -- --, ST # INVOICE <br />360 1 <br />T5o 3 A 3628' to 5 eu.,_ 101_05 R#t .0 W 3 "--7 <br />C-57 WC .7-WAIVER C-57 Letter of Authorization to sign permit .i1. Enc <br />44- CI VO END 29-02-001 <br />6/22/04