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I hereby certify ttrati <br />County Ordinance <br />Signed x <br />05/03/2002 13:09 20946834 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM <br />ORIGINAL <br />3 `Roo <br />Consultant / Sub Contractor <br />Tik4 <br />GIS Coordinates: X Q 65c 3 3 r? Y e/2c (416A.1 Township I 2.. Range rt.- 6 e; Section 7-3 <br />k) <br />WORK TO BE PERFORMED: <br />W WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # p i — 1-1 p <br />WELL # <br />'Other: Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ! MULTIPLE CASINGS? 13 YES a NO WELL CASING DIftr <br />CASING THICKNESS ,TYPE OF CASING; D STEEL 13 PVC 0 OTHER. A/041 <br />DEPTH OF GROUT SEAL / Cf TREMIE TYPE TO BE USED: 13 AUGERS >1:0SE <br />GROUT SEAL PUMPED;ies a No (NOTE: M IMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: C :Fitk <br />APPROX. BORING DEPTH r 13 BOLTED TRAFFIC BOX or 13 STOVE PIPE <br />CONDUCTOR CASING P -A,Ov POSED? ( if YES, list specitIcation))erey <br />A-f ci 7A-X-77 LA," <br /> / <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 />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 />WELL Location Z 0 ( Cross Street otk-L..fr• 4V-E City cr.-0 LC' f Parcel# <br />CZ 7 Assessor's <br />PROPERTY Owner Awm.,,A4.... 7 I( 7-e/ <br />cA, tyL) <br />dress ? Pr4e 4ci 6e'ite:Zip -3 Phone <br />Phone# C-57 Contractor Address // -3SID x, !MK:- City • v Zip Y. <br />L <br />?Vaic#7(16qA G <br />th- Address 79(-) OtP , Phone# 699 e <br />ESTRUCTION (choose type below) <br />_[] OVER-BORE <br />ii•SSURE GROUT <br />Erk,1 <br />TYPE OF WELL <br />a MONITORING <br />n EXTRACTION <br />VAPOR <br />a AIR SPARGE <br />1WIL BORING <br />OTHER: <br />-COMMENTS: <br />INSTALLATION TYPE <br />a HOLLOW STEM <br />O AIR HAMMER/DRIVEN <br />1:1 MUD ROTARY <br />NyidI6JSH POINT <br />1:1 HAND AUGER <br />El OTHER <br />L <br />-7 <br />epared this application and that the work will be done in accordance <br />s anc_Laegulations, and all applicable California State Laws. <br /> Title/Company C) a Et <br />with San Joaquin <br />_ <br />Print Name Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: V/2/c 2. <br />Application Accepted By Date Issued <br />Grout Inspection By <br /> <br />..)6(_;4, /pi \ Date / Final Inspection By <br />47t- <br />Destruction Inspection By Date <br />COMMENTS r CONDITIONS (NI <br />DEPARTMENT USE ONLY <br />24-ci <br />Area <br />Date <br />ACCOUNTING ONLY: <br />...- 1 ,--) - <br />A1D# is)/ If ' i k-,' ' (A--( cc f `f- '' 1 <br />‹...• ,...., <br />g.,-. <br />r ,•1 , --"._ r ,,L, <br />1 R V <br />PE CODES FEE INFO AMOUNT REMITTED CHEcK Is REC'D BY DATE PERMIT- <br />-- <br />INVOICE <br />,%-7-- ( ---,- Kr /272.) <br />C-57 Letter of Authorization to sign permit A Enerbathrritd 1/25/02 C-57 WC -WAIVER