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San Joaquin County <br /> <br /> <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: wm.sjgov.org/ehd UNIT IV <br />- Well Permit Application 3 Phi 2: 07 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR84 ,4TE- ISSUED T y <br />Application is hereby made to San Joaquin County for a permit to construct and/or install tliv.A-ri ced ThisAtkification is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County EnvironmenWieditti-r156Tartment. <br />froyrinkye.. 121)-04,„1 n, <br />.City"4"" <br />kr. o..2 c.) Assessors 1191-11 -03 <br />WELL Location 31-7 •C".= q vl Cross Street L v , 3 ' Zip Parcel# I <br />PROPERTY k't1 <br />Owner VI, 10f-rau,I9 Address-2169 MI r&klq6- City Artodes1-0 zipq53% Phone* cliiC 75 <br />C-57 Contractor AI keit-WWII Address AO mviri-te ktt- City Efraik. Zip'? .563 Lic#6 72&) Tphonot 16:1 'ill Li- 4104° <br />Lia 630V Phone# /A '4 0- 1006 <br />GIS Coordinates: X , Township Range Section <br />T, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) El DESTRUCTION (choose type below) <br />U OVER-BORE. DIAMETER <br />e_erwly ke 12.‘ 106 g PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />'5' 1 TT] d 5r,.&—heoJr -- Cenv Cro‘kk 4-o .211. <br />INSTALLATION TYPE <br />*HOLLOW STEM <br />g AIR HAMMER/DRIVEN <br />)(SOIL BORING a 1-.AND AUGER GROUT SPECIFICATIONS ft)(21-1,AND ent-tac <br />a OTHER: Q OTHER APPROX. BORING DEPTH (.90 %.koio a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PR9POSED Nk (if YES, list specifications in comment section) <br />COMMENTS: i-C" 56 ;1 /6-VO ttlYTO-Ar--C1 , tticiltEttt. arr- WkIllkttlx3 t1 Uttar (it le htiew G-w coe194v, , <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify th <br />County 0 d,ina <br />Signed x <br />b-e‘ciLe., <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 9 3 Sr S • )4t...,,0 9 <br />WORK PLAN DATED: I 015 D <br />(.4kivvY"-1,•% 1—• <br />Date ('U. I -z--osla Final Inspection By <br />Date Issued t S Area 6ZA <br />(,,AtA/LAc-4,N, Date t <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br /> <br />Date <br /> <br />MirAWAPPO MErTUPIIMI. G.so . AL <br /> <br />ACCOUNTING ONLY: AID* FAC# CTS-di 00 1 ILI 7 s 7 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SE -' INVOICE <br />3S-17 I <br />3 Col_ ".°4) Vist.06 4-036,00 2. 301-2_ (.4 It 11105 SR# 14 4 - -z.5 <br />Consultant / Sub CntrAtiVal(Ld 6-WEAVI'041041kdidress g31 k QI,J 12-c City9-DCHvy‘ <br />WORK TO BE PERFORMED: <br />1NEW WELL / BORING cc <br />U SOIL BORING # _) <br />-XIVELL # ML&J•-• <br />fl *Other <br />COMMENTS: rt&W- <br />TYPE OF WELL <br />O MONITORING <br />a EXTRACTION <br />Print Name Ar4-kwr E <br />t I have prepared this a <br />an egul <br />411.A1, <br />lication and that the work will be done in accordance with San Joaquin <br />and all applicable California State Laws. <br />Title/Company Vit6t, Cte0C*V11(011 <br />I 0 7-3 I 05 Date <br />izt.t rf 1 <br />Application Accepted By <br />Grout Inspection By <br />„. <br />CONSTRUCTION SPECIFICATIONS , <br />1 <br />- <br />,, <br /> ir , <br />. M:6014 <br />DIA. OF BOREHOLE ?" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: '1' <br />CASING THICKNESS TYPE OF CASING: a STEEL PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5,, i.,L,' TREMIE TYPE TO BE USED: *AUGERS g HOSE <br />a MR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04