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Application is hereby made to San <br />Joaquin County Development Title <br />WELL Location <br />PROPERTY <br />Owner <br />C-57 ContractorL,_C_A--Address 3 <br />6 f 7- • ;k7 Pa /hS I) City Ap b'S Zip S5_i.__26 Lic#653-90Phone#8.5-g <br />Phone#02iLeff <br />Consultant / Sub Cntri_Address PO- Lic# <br />GIS Coordinates: X , Y , Township <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />140IL BORING # <br />o WELL #______- <br />13 *Other <br />COMMENTS: <br />:2417 wes <br />San Joaquin County <br />Environmental Health Department SITE <br />600 E. Main Street, Stockton, CA 95202-30297 2 2°IniTiGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.or <br />aielFa 2 <br />IN1p\TRUmil.tliEsTRiviEsAL,,T UN IT IV <br />Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 0 c Assessors 11 lo 0 7 <br />Z4 si Vedit(crs's Street -(*r6-City __,_5t26-46"1 ZIP <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />5-2_64A) p-o <br />Address <br />Lth 57--b c <br />Range Section <br />13 DESTRUCTION (choose type below) <br />a OVER-BORE DIAMETER <br />13 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />MONITORING <br />1:1 EXTRACTION <br />D VAPOR <br />El AIR SPARGE/ OZONE <br />13 SOIL BORING <br />13 OTHER: <br />COMMENTS: /-74,5-4 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I have prepared this application and that the work will be done in accordance with San Joaquin <br />I hereby certify that County Ordina ces, Rules nd Regulations, and all applicable California State Laws. <br />Title/Company <br />Signed x <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE_IL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> <br />a AIR HAMMER/DRIVEN CASING THICKNESS__ TYPE OF CASING: <br />a STEEL 13 PVC I] OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: ii AUGERS r] HOSE <br />0USH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a HAND AUGER GROUT SPECIFICATIONS t C.; <br />D OTHER APPROX. BORING DEPTH 2' 3 51:-- 0 BOLTED TRAFFIC BOX or g STOVE PIPE <br />CONDUCTOiR CASING PROPOSED (if YES, list specifications in comment section) <br />S- _r-, i / 51 L^i 4 fe r- 5e i. ,..,.... / Re <br />Date <br />Date <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRES <br />WORK PLAN DATED: 43) <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date Issued <br />Final Inspection By <br />Area <br />Date 3 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroac <br />EHD 29-02-001web <br />6/22/04