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San Joaquin County <br />Environmental Hearth Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />' (209) 465-3449 Fax: (209) 468-3433 Web: www.sjgov.org, hd�l I <br />ORIGINAL <br />SITE <br />TIGATION <br />UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described, Thia application Is made In compliance with San <br />Joaquin County Oe elopmont Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. , r <br />Assenons <br />WELL Location wiva 6 1�� N. PI U(%IaRG 7 5� . Cross Street Gnivrlvnl/1 Clty 5�cN Zip V Paroolit Sl Wf <br />ROeERTYOw�XF ty 5 Yl Zip2JW L Phone# - y ^ RR - I <br />� i 9 <br />C-5TCOntractar (�f'!1 Addressla I�wi IYA, ClyZipLirA��85%�°5 Phone# �S��: <br />Consultant /Sub Cntr e4liS 1aA �1I , � ',tv l.pWu+/o �� i5t n Phnncf! 5,.ow,-/L <br />2 <br />GUS Coordinates: X31.0----) Y. Township V Range Section <br />w R D <br />NEW WELL /BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />13 SOIL BORING # M'"'` % 19.'Z 0 OVER -BORE. DIAMETER <br />11 WELL 9 n PRESSURE GROUT <br />n `Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP_ECIFICATIDNS <br />MAONITO ZING HOLLOW STEM DLA- OF SOREHOL t` 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z,1 <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSSrA 4D— - TYPE OF CASING: n STEEL 'VC 0 OTHER- <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALaS'iSS TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br />0 AIR SPARGE/ OZONE n PUSH POINT (GP or CPI )GROUT SEAL PUMPED: )VYesf a No (MOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1 Qr4 <br />0 OTHER n OTHI=R APPROX_ BORING DEPTH -SSI UBOLTED TRAFFIC BOX or d STOVE PIPE <br />CONDUCTOR SING PROPOSE=D (if YES, list specifications In comment sectlon) <br />COMMENTS. wl (r(Lj2jtit I(,Wls1 SGLE'1J 0r�7S� <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County OrdInan , Rules and Regulations, and all applicable California State Laws. % <br />Signed x 2: ;14 -_— TdWCompeny 5 <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /) / <br />Application Accepted By / / Date Issue <br />Grout Inspection By VkdA OILDate u 1 inal Inspection <br />Destruction inspection ev ate <br />1 -U <br />! Area <br />COMMENTS I CONDITIONS: r - <br />ACCOUNTING ONLY: l A1D# <br />PE CODES l FEE INFO I AMOUNT REMITTED I CHECK 9 RECD BY DATE PERMIT <br />C-57 WC-WArVEh` C-57 Letter of Authorization to sign permit— Cr <br />EHD 29-02-00 t <br />6622104 <br />IF REQUWIT 2 INVOICE <br />n# -d <br />�0/Ze 39Vc/ AI -CO ON Sf11CJis 50099L9069 96:L0 L00Z/6T/'60 <br />