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ga.Ke44.,D c_.s" 7 - <br />City Caivf&put, Zip 15"-7 4/2Lic# 71757 0 Phone# - 63 S - j(69 Address ,3C.32 Otyted.._ <br />fc..) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE / V if MULTIPLE CASINGS? YES 0 NO <br />CASING THICKNESS D. /..rit TYPE OF CASING: 0 STEEL ff PVC B OTHER: <br />DEPTH OF GROUT SEAL 32-' TREMIE TYPE TO BE USED: I AUGERS ie 111 HOSE <br />GROUT SEAL PUMPED: G Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Near C-eer rpAe 11- <br />APPROX. BORING DEPTH 11 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />beagotke- Seat terJees... jD4 2..cad-Mr ;rise-ado, #06 5e_. *COMMENTS: <br />TYPE OF WELL <br /> INSTALLATION TYPE <br />A MONITORING HOLLOW STEM <br />G EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR <br /> 0 MUD ROTARY <br />AIR SPARGE <br /> <br />0 PUSH POINT <br />l] SOIL BORING <br /> 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />WELL CASING DIA: e-- <br />Date Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />Date <br />Date Issued <br /> Final Inspection By <br /> <br />Application Accepted By <br />Grout Inspection By <br />Area <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <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 />7. 9 -52) Assessor's <br />WELL Location 2.7 o / A/. iserrt Cross Street clA714;me_n7 City sr;c*ri---- Zip "C-242 5- Parcel# 7-e:43 - /9 <br />PROPERTY <br />Owner <br />C-57 Contractor Ctse,rie <br />Consultant / Sub <br />Contractor //4g5 gnenev nprt esC--(Address/V3 3' /14 P'.2.--(4./e CityPhoe64 Lic# <br />Z rOo <br />GIS Coordinates: X )24. /6: I ,Y ° 5 t. s7.67 ,Township A/ Range <br />Address 2-7 714.4 C-eivr ,04 ve- City NO eol-ix Zip g'reval Phone# g o 2-- Z 3- 64117 <br />Phone# 2-- 7 2-g -070 7 <br />Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />/If WELL # /31 Ai- /0 74' el,e1 Vbe" <br /> Grout Specifications: <br />?Oe-war-A,;# 440 ;soCete.a;i7),- //E. cog‘es <br />DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />— See- airae_ite cec267eze.44 <br />*Other: <br />COMMENTS: <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 />/1, "4-47-, /tiles &Ay:tea-It-Ale/4CP' Signed x &el ---/lar`"/W Title/Company <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 270/ /V- Weak_ la-y Ye/A-- <br />WORK PLAN DATED: WP" //- F-0 /de/,n /- <br />ACCOUNTING ONLY: AID# A f'44 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE NVOICE PERMV,..1-SER'fteE-REWES14t <br />3150 k KtA-0 3 el tigtf 2— actt 2-• 2-5-02 j# 00 00 ? ---r---. -- -3 <br />C-57 V WCV -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />1/25/02 <br /> <br />Print Name f -e_77 — the-kti4.;e.,