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Area <br />date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date Issued <br />Final Inspection By Date <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: -2-1 —3 c) <br />AEC -EN _ WELL PERMIT APPLICATION FORM <br />3 <br />SAN JOAQUIN COUNTY <br />JUN 1 9 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICF <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 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 gfSan Joaquin County Environmental Health Department. <br />Li 1/0 5 PericiCstrc-- AVOIM, Cross Street / ' City .5 .(-0...K ronzip 95?/) -/eParc <br />essor <br />l# // <br />r iFik, F _., Ass's i m <br />PROPERTY Owner \.)&e,---1 Ci9_54-1- 0 Address 05 City 5-fix_1(1-9 c) Zip 75-Q6 7 Phone#1Z- (I) y no° 55(3(-1 <br />ity •OADo v il Zip Lic# 71750 Phonek91 Q <br />City Srok-lciarLic# 6 6c..);?.? 7 Phone# (-"q 9i, 7 /0 0 tg <br /> <br />Range Section <br />WORK TO BE PERFORMED: <br />nIEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # <br />'trkWELL # <br />Grout Specifications: <br />MITIGATION <br />UNIT IV <br />WELL Location <br />C-57 Contractor <br />Consultant / Sub Cntr A . Address b3 7 .544 <br />Ci9)(-490(•- Pri'll,Address 34032- °MEC- Clit 112 C <br />GIS Coordinates: X , Township <br />DESTRUCTION (choose type below) <br />a OVER-BORE <br />II PRESSURE GROUT <br />*Other: <br />COMMENTS <br />Signed x Title/Company R(;;)C 7- <br /> Date <br />DEPARTMENT USE ONLY <br />/ <br />Otrf /5' G 3 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? ULTI-LEVEL? a WELL CASING DIA: <br />5,- he Ovi CASING THICKNESS '10 TYPE OF CASI G: fl STEEL ?(PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 5-g TREMIE TYPE TO BE USED: 0 AUGERS X-HOSE <br />GROUT SEAL PUMPED: ' U No (NOTE: MAXIMUM .7E-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH16? 711SBOLTED TRAFFIC BOX or U STOVE PIPE <br />( if YES, list specifications here): <br />lik/c3 AN MI$40-1 o?/, ,7on_3 <br />TYPE OF WELL <br />AMONITORING <br />a EXTRACTION <br />0 VAPOR <br />a AIR SPARGE / <br />0 SOIL BORING <br />U OTHER: <br />INSTALLATION TYPE <br />HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />Ozone fl PUSH POINT <br />a HAND AUGER <br />11 OTHER <br />*COMMENTS: <br /> Apv<0 <br />CONDUCTORpsING PROXED? <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 Or inances, Rules and Regulations, and all applicable Californiaate Laws. <br />flc <br />pt <br />Print Name <br />ACCOUNTING ONLY: ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVI F&j INVOICE <br />6D1 1 ILULJ .34/ --- 2-1q0 6-1-0 a(- cts7-- C:6R OD 311 <br />C-57 V WC V -WAIVER C-57 Letter of Authorization to sign permit 8/29/02 <br /> <br />*F.