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Signed x <br />Print 3-6-77; C-1,Attr' OAAJA-.. <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 />SITE <br />MITIGATION <br />UNIT IV <br />Mil DEC -7 PH l 39 <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 describe . <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmeg <br />WELL Location LI L/C1 N/Q0,41c,c) 12c). I C>tecirjr, Cross Street W;lcoX 12;3. City -1--c.j01-;,, <br />PROPERTY <br />Owner --rneci- Ati b^12.Cc N: Address PO a\., City Zip ciS-115- Phone# (WI 2S5b <br />C-57 Contractor 04; [Jet I F./ Q. Address "7100 01.014,4 A . <br /> <br />CityEs-- Zip q9;-D3 Lic# 611,17 Phone# (7er) 17o t1 <br />Consultant / Sub Cntr AG-E- Address 7 SkAav.., 4. City Cs.itock-fo-1. Lidt (ogOZTI Phone# (Z0)1/ l 6-7 occ- <br />.QUI1,1 COUNTY <br />lo compliance with San <br />lErtritElPtT PIENS <br />Assessors <br />Zip 15-215- Parcel# 69:1-100 - Sq. <br />GIS Coordinates: X , Y , Township Range <br /> <br />Section <br /> <br />WO( TO BE PERFORMED: <br />g-KEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SitIL BORING # <br />-,TWELL # (.49 <br />TYPE OF WELL INSTALLATION TYPE <br />a MONITORING ir<OLLOW STEM <br />a EXTRACTION 0 AIR HAMMER/DRIVEN <br />g'‹APOR a MUD ROTARY <br />a DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE I] MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: '2-6 <br />CASING THICKNESS L. q 0 TYPE OF CASING: a STEEL alK/C a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 1116GERS a HOSE <br /> <br />a *Other <br /> <br />COMMENTS: 3 1-c, ;41' 1,5.5 3 ,,,„A tc <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 17r 1/1I -Pci-I-1,-,-1\ (-,e.4- <br />0 OTHER: a OTHER APPROX. BORING DEPTH 36 / (00 1 'LTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED vi.0 (if YES, list specifications in comment section) <br />COMMENTS: <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 Ord'nances, ules and Regulations, and all applicable California State Laws. <br />Title/Company ("eel <br />Date 12-C., --c)(; <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Li 00,4-, coo g_rj. <br />WORK PLAN DATED: cr I "3-- <br />Application Accepted By (A%rtA..v.t ci. <br />Grout Inspection By Lr>rvv.0%..e. <br />Destruction Inspection By <br /> <br />Date Issued 1 2- I illato <br />Date 121 ((otr, Final Inspection By - <br />DateDate <br /> <br />Area <br />Date <br />- <br />Date 12. I( 510 EP <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3 5-1, t <br />3 c 0 3 A%-felfil (Al rz.filio SR#0 0 ,--ick it 5 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit t/ Encroac ment <br /> <br />EHD 29-02-001 <br />6/22/04