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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ate <br />ate <br />• <br />"d <br />0 k L-1 t7t-Q.. 17 0 G(4 a/ VC. it%eil <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />, bow,ei-re p <br />Z.Final Inspection By Date F-77-4Vb <br />ACCOUNTING ONLY: <br />5 c ,,,„C/, Ito ,A) 4) 0 6 r- ,;. !.1 <br />AID# <br />c .L41 b . <br />rertf <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT INVOICE <br />3 Lf00 <br />• /...1C Jr. n <br />-WAIVER C-57 Letter of Authorization to sign permit ncroac WC C-57 <br />Date Issued <br />WELL PERMIT APPLICATION FORNI <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 /> <br />City Ty...4c zip ?.3.37‘ PAasitesels 's 4sor fr4 /3 50 <br />PROPERTY Owner P/ie tiAreR"i's Address P4 Box 5.2.52 City ne.I.S4ov7e4 Zip Pfl../g4 Phone# Veig: - vs) 7 <br />C-57 Contractor are4r Pies T Address /5 7?? i/444EY — City ABIOrA04-Zip 4?23'k.7# 51 qine#009) 3619 - c9.2co PR 14A IA, a AL Vb . <br />Consultant / Sub Contractor Addre, City Lic# Phone# <br />6 .2 o,e., i., / <br />GIS Coordinates: X Iii .3/ 70. A ,Y W hi/ °,)$. A Township Range Section <br />70,e'rtho 4 / OP 36e#11111- secriew WORK TO BE PERFORMED: <br /> <br />XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") I] DESTRUCTION (choose type below) <br />O SOIL BORING # [I OVER-BORE <br />G WELL # ['PRESSURE GROUT <br />*Other: Grout Specifications: ex.:111C11-riC__ i-c.)u-i- 3: '1. ,,,-„( , lid <br />COMMENTS: <br /> <br />_ <br /> <br />(L-n ep-,4„..1-_& <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />i <br /> iv <br />13 MONITORING [] HOLLOW STEM DIA. OF BOREHOLE if MULTIPLE CASINGS? 0 YES O NO WELL CASING DIA: V <br />0 EXTRACTION ys‘kIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 13 STEEL XPVC 0 OTHER: <br />[I VAPOR [I] MUD ROTARY DEPTH OF GROUT SEAL '\" tier TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br />fl AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:Xes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ecrifEiwir'Grw-1 3C1. SCI id <br />0 OTHER: p OTHER APPROX. BORING DEPTH 4310 ic"7" XBOLTED TRAFFIC BOX or f] STOVE PIPE <br />11 ,s1 4 x i Ave4Ar or 'riVRee CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />"COMMENTS: ,—, <br />_, <br />emi i 7) ,e/iva 141E4 4 S it)/ < ( ze I" s )-0od z Pb ,ii ?.s ,-Zieu EWA,' <br /> <br />eo Airi4 /41/01447 -10•0 es- t-A) eoceA.)-ezerb 4 )r - 7we 14/4 re TA8 411: <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 have prepared this application and that the work will be done in accordance with San Joaquin <br />nances <br />Date <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />I,pplication 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 />NELL Location 30350 S, )-24cy 34')1) Cross Street <br />I hereby ce <br />County 0 <br />Signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />piwcwo8 (44d4 e SAA) <br />40040 l-s ar2a4: ,ae„-ns, and all applicable California State Laws. <br />4111., Title/Company EA-WIZON/gdwr.44 SeiaseihsorSrc Arpt,c_ <br />ci2°t)