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INVOICE <br />C %A I r <br />SITE MAP IN UNIT IV PILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout InspOCrion By <br />Destruction Inspection By <br />Oale <br />Dale <br />Date Issued <br />Final Inspection By <br />ZOO Z-- Area <br />Dale <br />PE CODES FEE INFO AMOUNT REMITTED <br />011111111.1.111.11MMIll <br />-WA T.VER 4.152 It:ter of Authorization to igo_Prrilit <br />CHECK <br />9/27/00 <br />COMMENTS/ CONDITIONS: <br />MAY -20-2002 03:113p FROM: <br />TO: 1916383'1084 P:3/5 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA_, 95202 <br />(209) 469.3449 <br />hISB) -REFUNDABLE PERMIT EXPIRESJ YEAR FROM DATE_IJOA_IED. <br />koplication Is hereby made to San Joaquin county for a permit to oonotruot endlor Install the wort described. This appliceilon Is made in compliance with San <br />loaquin County Development Title, Chapter 9-1115.3 end the Standards of San Joaquin County Public Health Services, Environmental Heal trlDivision. <br />CI t 2 S4 1\) 14`.-51"-`""1 " Cross Street Ll tdactailefiear City Ac-A" <br /> <br />T77. Zip 475-27-0 PAassrcec15/$3°Cr;s/ 7 - <br />tint. Location <br />05-D34. <br />M10PERTY Owner %•/"Trtiy iCII4 eam"44 Address W° ologre city SAcaeir.,1 - 3E33 - <br />77.-57 Contractor A.siN 6-mi4allaatollitknal Address 3"6 .SrieV..A1 RA c V,41,J.,974ari 9 S7'5.41-Lietsc___21210 Phonee A:19 - 272 - 3,570 <br />Consultant / Sub Contraclor Ar_.1.44-‘54:Pr AddreSS 67-3 4'71 CIty_lop, Li ott_.phones$,249-361- 0 42- <br /> <br />Range Section <br />O DESTRUCTION (choose type below) <br />fi OVER-BORE <br />II-PRESSURE GROUT <br />SITE <br />MITIGATION <br />UNIT IV <br />GIS Coon:lin:les . X • y <br />WORISTO BE PERE oRMED: <br />ANEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCK HANQVuoER. OTHER') <br />*SOIL BORING <br />0 WELL <br />, Township 41%3 <br />Grout SpecincatIons: <br />'other: <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING a HOLLOW STEM <br /> <br />()EXTRACTION 13 AIR HAMMER/DRIVEN <br />()VAPOR 0 MUD ROTARY <br /> <br />()AIR SPARGE 2rPUShl POINT <br /> <br />SOIL BORING 0 HAND AUGER <br />rt OTHER. LI OTHER <br />OIA. OF EK)REHOLE MULTIPLE CASINGS/ I] YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYK OF CASING: °STEEL fl PVC 0 OTHER; <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: U AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes <br />°No (NOTE: MAXIMUM FREE.FALL DEPTH IS 30') <br />GROUT SPECiFICATiONs: <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED'? <br />"COMMENTS: <br />LL TH <br />I her by cr <br />County Ord <br />that I •re <br />7ces, <br />NIT hi INSP <br />this application and that the work will be done In accordance with San Joaquin <br />egulations, and all applicable California state Laws. <br />Title/Company 14.0A6611, o: CPPeiteirlataS -weg.relsA, biL <br />'SPalro,cloARS Xrc <br />PERMITS. <br />NOT OFFSITE 8 ORI N GS REQUIRE ACCESS OR ENCROACHMENT <br />45 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />()BOLTED TRAFFIC BOX or ri STOVE PIPE <br />(Ii YES. Ilst speclecailons here): <br />Signed <br />S WMz <br />Print Neme pEPARTMEN_DAL.ONLY. <br />cietc_0ID