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I hereby certify that I have pre re this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regu nd all applIc e Cal ornla Laws. <br />Signed <br />Print Name <br />AREA <br />Title/Company N t C-4- <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: .2-deN <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY 4/ <br />DEPARTMENT DEPARTMENT USE ONLY <br />/P.0 C • <br />DATE ISSUED 21/ "1/01 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 4 ( 44 C\--r•L(Cross Street City c.',IVe Zip T, ?o; Parcel # ! <br />Assessor's , 3 0 <br />Properp, <br />Owner yo: wt 4 irc.e..•.1•-o-n Address 2 IP (0 - City c:(-P./.1 Zip P(Jorte # 41) <br /> <br />"Pi- City 5.4-vc Lie #06381Phone 5- -13 7- I '7- C-67 Contractor?Ve c Address 7 3 c s." t <br />Consultant/Sub Cntr Address <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, °NEW) DESTRUCTION (CHOOSE TYPE BELOW) <br />0 SOIL BORING# 0 OVER-BORE DIAMETER <br />171 WELL # RCPRESSURE GROUT --5 '4" 'me fls, <br />0 *OTHER ' GROUT SPECIFICATIONS <br />1. u' e-t ( C- ci es c.--0 , .0 .." ,•(.-..--A c <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: 9' <br />CASING THICKNESS '.-PC-44 -1-0 TYPE OF CASING: 0 STEEL APVC 0 OTHER <br />A <br />DEPTH OF GROUT SEAL - TREMIE TYPE TO BE USED CI AUGERS 0 HOSE <br />GROUT SEAL PUMPED: El Yes gl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />,—e_A e r -k '5 • <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, Ilst apecifIcellons In comment aectfon) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION <br /> <br />DATE <br />COMMENTS/CONDITIONS: i?..-1.41/C 7:2114/1AA'Arti 5-JP he-0.5-02,t/7O4 <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />011 02 b 0" b0- t -V-i I /-I-C 2-f/7/d 9 SR# 60 (61,13? <br />C-57 WC -WAIVER <br /> <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> <br />ENCROACHMENT DOC <br /> <br />City Llc # Phone <br />COMMENTS: 4. <br />( e, <br />TYPE OF WELL INSTALLATION TYPE <br />'MONITORING KHOLLOW STEM <br />El EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE/OZONE 0 PUSH POINT (GP OR CPT)._ <br />CI SOIL BORING I] HAND AUGER <br />o OTHER: OTHER: <br />GROUT SPECIFICATIONS <br />WELL PERMIT APP END 29-01 1115107 (WEB)