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kJall a/Wapiti. m4-..1JUIIIL, <br />Environmental Health Department <br />SITE <br /> <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: wvvw.sjgov.org/ehd <br />UNIT IV <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 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 />WELL Location /027/,_5-: fr-r/p/._ Cross Street ee 17,4 A^ City 5".7C-kA d---2 Zip 752,9 (., Parcel# <br />Assessors <br />PROPERTY <br />Owner/7r' /(-e---re-c14 4 / Address /249,6' Z04-5-i4)A2 City,5 1.2 VD.Ca-- Zip 9.5732Phone# 5 for Z23 c576 <br />C-57 Contractor4/D/Vik.14'il Dit//hc;f Address532:-' 1.ityx=,0 7/ Lic#7/00?Y Phone# -2 3? y el300 <br />Consultant / Sub Cntr fr"0-2 Ze-0-t--;"'i ebfAddress/q6 /?(41,77er-SKCity4/Coo(‘ iLic# Phone# 3716- <br />GIS Coordinates: X Y , Township / Range 6 47 Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (CPT(EOPROBE, YDROPUNCH, HAND-AUGER, OTHER") U DESTRUCTION (choose type below) <br />SOIL BORING # <br />El PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIO <br />O MONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASI ! MULT WELL CASING DIA: <br />[I EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF ' " 1G: g ST PVC a OTHER: <br />O VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ,-------- ,--- TREMIE TYPE TO BE USED: 0 AUGERS KHOSE <br />a AIR SPARGE/ OZONE X'USH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />XtolL BORING a HAND AUGER GROUT SPECIFICATIONSiia47L Cr‘-'7e<.17 - < .5"- <br />O OTHER: a OTHER APPROX. BORING DEPTH Vo 1 y- 90 <br />4 <br />g BOLTED TRAFFIC BOX or I:I STOVE PIPE <br />CONDUCTOR CASING PROPOSED /70 ,z-a— (if YES, list specifications in comment section) <br />COMMENTS: 5-- YO i 6-eo/r614.e 4.174-hae_c v.--_..? 90 /6.ece-oha- -A /- /6:1- A ‘e <br />4.-/ ./-47 lixe471 C 7 e., Y- C.4•2 -'*i'e- 67/G-7 / 4 -r c/.-:g <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 /> <br />6;'.% iete Title/Company <br />Print Name a ;-/- Date 3/ 0 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDREI <br />0 <br />S: :',1-( / ., e4 2J4— <br />WORK PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />- ACCOUNTING ONLY: AID# FAC# <br />,..._)00 1 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />ciRL. <br />P SERVICE REQUEST # IN, ICE <br />4 3 (, („ q o 313/6 6 sR# <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />Iv <br />El OVER-BORE. DIAMETER <br />U WELL # <br />rOther 6e6 /9,-oh-e •/-e,lit-- A045 <br />COMMENTS: ,5 yo 6e0,,o4,2_ 7le.OL IAnk5 7 .27,22 / 27,2 -r1 90 ' Poio,-0e, <br />) <br />71cf 4cA'S 3 -1) 7 3 -a / 3 <br />Signed x <br />Date <br />Date <br />3 <br />,31,166 <br />Final Inspection By '-'11/-Zio-fati "I'to Date <br />Area <br />0 <br />C-57 WC -WAIVER <br />EHD 29-02-001