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/ / / SiL7) SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: .2- <br />Al ACCOUNTING ONLY: <br />DATE REC'D BY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS t CONDITIO <br />FACrP <br />PE CODES FEE INFO AMOUNT REMITTED CHECK* <br />L 3 5° ° 6 /c2-) t 1(4 SR# 3 S <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encro <br />INVOICE <br />9/30/02 <br />1 <br />PERMIT SERVICE REQUEST* <br />Date Issued r;- 1.1 6 _3 Area (I( <br />Final Ins ctiortily Data <br />3 <br />,f ) 7 U. <br />FEB I 8 2003 <br />EMIF\ON1V1b, <br />PERMaiS <br />01/03/2003 14:18 2094683433 <br /> <br />FIFTH FLOOR PAGE 02 <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct andfor 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 Heath Department. <br />A$Se ssors <br />WELL Location _L.It2c\N f)g It/ (g16/47 Of: WY) Cross Street Fie.z.or-ids,wr City STOCV-1-r--1 Zip 2S2-0 2- Parcel* <br />PROPERTY Owner 0 IT-1 \(...-t-or--1 Address '125 N. EL Doe-PrDo St-.CitySTocKrar-A ZIpi5202-Phone#(20)) 937- 8341 <br />Rikts1C1A, <br />C-57 Contractor CFA SCP.IDZ. VO,It..)----//-AG Address 3L032. OM ke ei Re (--E City cce--oc:AJA zip95_742Lic$7 t 75 ID Phone/0(710(038- ((LA <br />RANC0-7..) <br />Consultant/Sub Cntr S tr,ir • Address3035 Pao5PC-c7 City Cva-Dov L c#71t3111 <br />PA-e-v- 1721v tE- <br />GIS Coordinates: X ,y_ Township Range Section NONE. JiVE.NJ <br />WORK TO BE PERFORMED . <br />El NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />a SOIL BORING It <br />fl WELL # <br />0 *Other <br />COMMENTS' - r1/4.A.LL '112 4-S‘ <br />. <br />TYPE OF WELL <br />0 MONITORING <br />fl EXTRACTION <br />a VAPOR <br />a AIR SPARGE/ OZONE <br />SOIL BORING <br />fl OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a HOLLOW STEM DIA, or BOREHOLE a MULTIPLE CASINGS IJ MULTI-LEVEL WELL CASING DIA: <br />a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />O PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yo g n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (it YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />COMMENTS: <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordin noes, Rules an Regu tions, and all applicable California State Laws. <br />Title/Company Sr-2,J i cs(L GEDI tY--) t ST <br />Date 7-41'7103 <br />SITE <br />MITIGATION <br />UNIT IV <br />Rhone& (91;2)853 - [Vint -) <br />TRUCTION (choose type below <br />OVER-SORE. DIAMETER 1011 <br />° PRESSURE GROUT <br />GROUT SPECIFICATIONS NOPFT <br />(?7q1S (4-1-41) <br />S'fir4s4-2-1-, V\J pvc . <br />)<D <br />Signed \-1 <br /> `-7 <br />Print Name El re 1,4,7-47 <br />DEPARTMENT USE ONLY