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°F 14ctiCio.r\ (No AM <br />10 LArnbet I Address i5 AL i) City •--•'/"-oc r 0.1 n p 95 zk, Phone# v.0() 937 SW/ <br />Address 40:).:4- 0,-1 C Aci e City c oFi S 7 41 a Lic# 7/7f'' 8f)hkrio <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date Issued Area 106 <br />Final Inspection ByUla, Date Date <br />Date <br />WELL PERMIT APPLICATION FORM <br /> <br />pr-RISINAL TE <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />MITIGATION <br />UNIT IV <br /> <br />oi41 69s <br /> <br />Application is hereby made to <br />Joaquin County Devel pment <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />San Joaquin County for a permit to construct and/or install the wcrk described. This application is made in compliance with San <br />Ti Chapter 9-111 .3 and the Standards qt San Joaquin County Environmental Health Department. <br />Assessor's <br />Cross Street City V C Zip Parcel# WELL Location Os <br />77^,/ <br />PROPERTY Owner <br />Ye PrE <br />C-57 Contractor <br />Consultant / Sub Cntr A. G. . Address 837 41,,, RD city -Cioc K ile\Lic# 680 t 7 Phone# Vb 7 1/40 <br />GIS Coordinates: X <br /> <br />, Y , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (OPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />..;,RWELL # tyykr-15, MIAPAMW`171/11,4 -0,40 irq" 6 <br />*Other: Grout Specifications: <br />COMMENTS SEE A I-4 AcliE.42 C1'7"- i SToc-KrivN c.14._1,1 4,10,1 4- itiCfKi <br />0 DESTRUCTION (choose type below) <br />OVER-BORE <br />11 PRESSURE GROUT <br />TYPE OF WELL <br />BAIONITORING <br />fl EXTRACTION <br />VAPOR <br />AIR SPARGE / <br />SOIL BORING <br />I] OTHER: <br />*COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 HOLLOW STEM DIA. OF BOREHOLE r.-, MULTIPLE CASING $? a MULTI-LEVEL? WELL CASING DIA: " <br />—37-iiiTv/i2. -- , <br />0 AIR HAMMER/DRIVEN CASING THICKNESS 4 p TYPE OF CASI —IFS tEL 0 PVC L] OTHER: /PH Jr-, <br />0 MUD ROTARY DEPTH OF GROUT SEAL 5 (..) 1-1 1- TREMIE TYPE TO BE USED: 0 AUGERS i] HOSE <br />Ozone a PUSH POINT GROUT SEAL PUMPED: ,Ves 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER <br />25'1 <br />GROUT SPECIFICATIONS: Pa R-1144,,41) <br />II OTHER APPROX. BORING DEPTH I <br />; <br />BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ?J O . ( if YES, list specifications here): <br />Pkil-)5( RFrcr 7.- WoRK P16A, :14 77.` 9 /1 /9/0/4 i'L Z - 3 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 4/4' P tt140 ( -Cs-j).4--- Title/Company <br />Print Name Name 77;:yt 0 -7-ki 7 ‘," . Cv / /01 A N Date / 0/1 r/ 3 <br />DEPARTM T USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD ESS: 0/05 aeie 2.-eff <br /> <br />ACCOUNTING ONLY: AID# 6-Rzr,e)36 locs ( <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMIT / S -• ' ' • I # <br />350/, mw ic?- t6i42-1 /t4:-. fo-15 .*fe. 36 I <br />C-57 WC ,./-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />PeA3A.v 03 —11 W