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WOR TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # j <br />NkVtLL # 3 (A.als <br />Ij DESTRUCTION (choose type beiow) <br />O OVER-BORE <br />0 PRESSURE GROUT <br />*Other: Grout Specifications* <br />WELL. ERMIT APPLICATION FM <br />N OWEN i Ai. HEA1.11t <br />,NIT ppvICE SAN JOAQUIN COUNTY <br />ENVIRONMFFAL HEALTH DEPARTMENT (EHD) <br />03 FEB3111 63.taig, Third Floor, Stockton, CA, 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 DIOg 51", Cross Street /1^0A 5.3-- City P41.14-4e.C.A. Zip 7573 <br />PAasrsceeslAt Assessor's 0,10 <br />-0 <br /> f <br />PROPERTY Owner c4L7 iell\con-Vecck_ Address /001 ( 444e,1 $4-• City Algilise cc( Zip 9C73 Phone# t <br />C-57 Contractor t+Cargltd-dress F--:,:t25e ( /iv? City kr,lf,(t; Y.2-Lic# 9 711one# frad3g _ 7C <br />Consultant/Sub Cntr /16.-e Address -7 Lick i,A.1 City 5J c#S')!5 Phone# c-A 7 -70OG- <br />GIS Coordinates: X , Y , Township Range Section <br />COMMENTS <br />TYP OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />. ONITORING OLLOW STEM DIA. OF 30REHOLE 4 l' MULTIPLE CASINGS? 0 MULTI-LEVEL? I] WELL CASING DIA: c <br />1:1 )(TRACTION 0 A; <br />) ° <br />IR HAMMER/DRIVEN CASING THICKNESS a.41. t-(0 ITYPE OF CASING: a STEEL 24-PVC 0 OTHER: <br />B VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL < Feel- TREMIE TYPE TO BE USED: *AUGERS B HOSE <br />B AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: B Yes ,No (NOTE: MfXIMUM FRE i-FALLREPTH IS 30') <br />0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: /1 /19 fc-ttiaoek 46 61qt/cos J1_0 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 30' o BOLTED TRAF C BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED?/1'O ( if YES, list specifications here): <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 Ordinan s, Rule and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 6e0 )0y <br />Print Name Br 'Cori .114 I <br />SITE MAP IN UNIT IV FILE, ADDRESS: vA).e..A,A,N. cri <br />WORK PLAN DATED: I g OGA-• <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />i---- <br />(A>uvt"not--\ Date 241110 3 <br />Date <br />Date Issued <br />Final Inspection By <br />Area <br />Date 21/ 7/03 <br /> <br />ACCOUNTING ONLY: AID# <br />PE CODES CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVI U.EST # INVOICE <br />3 5-0 ( __OgC1'00 I 5(;, 2_0 (AL // D3 6 ikc:20 3 2-3. 2:3- <br />frWl <br />Date <br />DEPARTMENT USE ONLY <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign p ncroachme <br /> <br />8/29/02 <br />