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AID# ACCOUNTING ONLY: <br />, ize t ten,4 <br />SITE MAP IN UNIT IV FILE, /ADDRESS: '° °' <br />WORK PLAN DATED: *S-7,3/,-- <br />(A4AAncot <br />Final Inspection By <br />5. . <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />Date Date t1i2-s-10- <br />Date <br />Date Issued LI I) C2 <br />coN <br />AMOUNT REMITTED <br />C-57 WC -WAIVER <br />=artt <br />DATE <br />sR# 0° 5 L10"i ctf <br />ita5A1 <br />1_ <br />PERMIT/SERVICE REQUEST # INVOICE <br />C-57 Letter of Authorization to sign permit_ Encroachment doc___ <br />CHECK # REC'D BY <br />1 <br />PE CODES FEE INFO <br />A-9,0 I <br />WELL. PERMIT APPLICATION iRM <br /> <br />- SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 />,>/ Assessors3_,„ • <br />WELL Location, 22Pc76 6'4 ".4 5 7 Cross Se City / (aA, `--ed-C Zip e'/.1.J Parcel# <br />,, <br />6,71 <br />PROPERTY Owner_f- et'S 5//m 41-Address <br />, <br /> City nSec.;1 Zip A.-53)--Phone# <br />ContractorOeilfe-C" ottof--- Address)AP6-1 .- /11/471V-Ze7---/City_rwifieft-/ Zipf52645-Lic# "tione# 211' <br />\-'Consultant / Sub Contractor f()), Addres. s /0() n49 5)71:- City .,n/gkLic..3-9,010qPhonett67/0 <br />GIS Coordinates: X , Y , Township Range Section <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />M -->. <br />rr <br />XONITORING OLLOW STEM DIA. OF BOREHOLE 1:)) MULTIPLE CASINGS? 0 YES NO WELL CASING DIA:77 <br />1:1 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS. •• 0 TYPE OF CASING: 0 STEEL_At PVC a OTHER: <br />['VAPOR a MUD ROTARY DEPTH OF GROUT SEAL r TREMIE TYPE TO BE USED: fl AUGERS 0 HOSE <br />1:1 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0 Yes -Nn (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />XASOIL BORING ---> AzHAND AUGER GROUT SPECIFICATIONS: <br />fl OTHER: °OTHER APPROX. BORING DEPTHEL.)ABOLTED TRAFFIC BOX or G STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />-. -r7,- 7E,•-,--2p . <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Title/Company <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br />SITE <br />MITIGATION <br />UNIT IV <br />GISVkl <br />02W7 <br />WORK TO BE PERFORMED: <br />fQ1EW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (choose type. below) <br />SOIL BORING # 3-> e OVER-BORE <br />ITV/ELL # A 0 PRESSURE GROUT <br />*Other: Grout Specifications: /t),,"---C4,--/-Li.,,-4/ <br />COMMENTS: <br />9-0z z4-5 1(4-9,t-7L- <br />*COMMENTS: S <br />Date ///7?-.4)--