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Application Accepted By,..."" <br />Grout Inspection By <br />Destruction Inspection a <br />Date 0 - 28 -0 3 <br />Print Name MIAN.3 ‹.._a.Ag.SE2' <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Al D# ACCOUNTING ONLY: <br />COMMENTS / CONDITIONS. c <br />e- /t4 <br />FAC# S1 45 /ct s-r- . <br />PE CODES FEE INFO AMOUNT REMITTED REC'D BY DATE rsLF(Q INVOICE <br />ci.C)Ci -2_ I 07- cig <br />C-57 WC -WAIVER C-57 Letter of Authooizotiop-tu)sign permit Encrocic men oc 9/30/02 <br />- Area <br />Date <br />k <br />CHECK # <br />JAN -10 -1999 11:190 FROM: <br />7 '2094683433 P:2/2 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (El-ID) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 r..,(0-.14)5(611--V 33 <br />IS 1..21-11_kLinK)AE_ILE_Ele_rn_II PIRES 1 YEAR FROM DATE ISIMEL) Application is hereby made to SA n Joaquin county for a permit to construct and/or Instal! the work described. I Ns application is made In compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 4420 C hiebeiLs.Caies RI? 's•-•.- 017_0.10-02 / Ac ASSessors WELL Location / ci lac 6. Ai ST, 4.1;1 cvi Isit Cr=et )./.0..perzip‘c City ACAim Po Zip 41C2:1° Pancel# CD tl -09 0 <br />Owner_""" -n'-` <br />D. ..5 1,_ <br />'.7 Address 44 v t-to.re. 1:24' City_ tUonci_c-i 110 q 4 G142 Zip Phone# AJ Fkari n <br />...,--411"-s6 415 (40 R.1 Aa......e... -' 7 C-57 Contractor 6t2cr.G- OR ii_t...0..‘ i' v Address t.City ""c.2 71p "5453Lic.# Phone# q 26 3t 1 52300 <br />— <br />Consultant / Sub Cntr 1)..k:- CZ.NRASele- V.- E • 4 0'1e:531110 Hi-14.7&-xy-7 ie.' CI tY_AvOt-q&J Ucti C 217-10 Phone# S3b 823 Z 'Seo <br />GIS Coordinates; X , Y • Township .4 (4 Ranoe. 7 e':' section 3 I <br />WORK TO $E PERFORMED: <br />i[NEW WELL / BORING EOPROBE, HYDROPUNCH. HAND-AUGER, OTHER*) 1:1 DESTRUCTION (choose typo below) 0 SOIL BORING # I] OVER-BORE. DIAMETER II WELL # PRESSURE 1) "Other GROUT OUT SPECIFICATIONS COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE .21101.9SPECIFICATIONS <br /> <br />MONITORING U HOLLOW STEM DIA. OF BOREI-10LE a MULTIPLE CASINGS IJ MULTI-LEVEL WELL CASING DIA: eac <br />a EXTRACTION 0 AIR HAMMER/CRIVEN CASING THICKNESS 14,1- TYPE OF CASING: I:I STEEL 11 PVC a OTHER: 1] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Evo-I:leoPrm TREMIE rYPE TO BE USED- I:I AUGERS 0 HOSE fl AIR SPARGE/ OZONE MUSH POINT (GP or CPT)GROUT SEAL PUMPED A-Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') -itS011_ BORING (1' r 0 HAND AUGER GROUT SPECIFICATIONS <br />1:1 OTHER: a OTHER. APPROX. BORING DEPTH 40 -i-t,‘ 5 ['BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (it YES, list specifications In comment section) <br />Title/Companyal <br />SITE <br />MITIGATION <br />UNIT IV <br />COMMENTS;_ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <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 Ordinances, Rules and Regulations, and all applicable California State Laws <br />Signed