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TYPE OF WELL <br />IrMONITORING <br />O EXTRACTION <br />O VAPOR <br />INSTALLATION TYPE <br />11 HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />O MUD ROTARY <br /> Area <br /> Date ILI, /LA-- Final Inspection By Date 5( -el( (.41- <br />Date <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS• <br />---15-trity San Joaquin County <br />c\ <br /> <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />Environmental Health Department ,-1 <br />R 0 <br />O RI WEN <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd iviA 200 , UNIT IV <br />Well Permit Application <br />ENVIRONMENT i-IFALTH <br />1 1 <br />' <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 />Assessors WELL Location '7 kc), '\1.t-tUmT-F12... Si. Cross Street F Lo R-IN ST. City s-rc,c.x._-ro ;I Zip ri5 2.02. Parcel* <br />PROPERTY <br />Owner vi mcE.JbL Address i".o dc.x 1...c10 ka City "crock.rtsN.1 Zip 15202_ Phone* t 95 (2 - C> <br />C-57 Contractor CASC Ft()E OVSLLItiCT Address ;tr. 2 °M EC Ct cLLE City RANcw.:, Zip As -N 2. Licit 7i75 t o Phone* (.9 Of, ISC -SC lt <br />IA <br />City sroc j Lic* Phone*/ 20'1)i-IG - t <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />O SOIL BORING # <br />tAW - tit.4 -11.11w -12 ,1-w.)-11 <br />a *Other <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _22__ <br />CASING THICKNESS5r vlEt.)..i._f .40TYPE OF CASING: a STEEL RPVC a OTHER: <br />DEPTH OF GROUT SEAL.43545%.‘0411i.=142) IV (T"REVIEI-1‘4TYR TO BE USED: KaUGERS a HOSE <br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: )1 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS CI rY1'.' E IL <br />O OTHER: a OTHER <br />(1.- <br />y \A APP:OX. BORING DEP_ITH:,-•:/ ii.w:crie, <br />(. <br />7,34111— BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NA, <br />AE <br /> <br />, <br />(if YES, list specifications in comment section) <br />COMMENTS: F LE A SE EF EP _ <br />o h.s.t_ <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 <br />Print Name F)ECIC.._`? LEE <br /> <br />Title/Company SI-A.F F E CiTSST /AO r4 EI) Et:EN vtec-\'.1i el\IT/A1— <br />Date .7) <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1," • t- • <br />WORK PLAN DATED: t <br />AbvAiNacE0 <br />Consultant/Sub Cntr fsi vr ikc.4.,-.1EN•mi_.T.au Address R . <br />a DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />ACCOUNTING ONLY: AID* FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE EST # INVOICE <br />3512‘ <br />,5 01' <br />tet . 05, <br />a f.5-. a? .)-/-A- Q`" 1:5"-5-1- S. Ap. _ 31 s•((c), <br />C-57 WC •4( -WAIVER' <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit