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TYPE OF WELL INSTALLATION TYPE <br />MONITORING A'HOLLOW STEM <br />EXTRACTION <br />VAPOR <br />AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />WELL PEttlIT APPLICATION FOR. <br />N JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 />Assessors <br />WELL Location ilk) uJ . Yu-Jim k Ave, Cross Street 8. tt000 Pi. City Wilt(fel_ Zip /5 3 31 Parcet# 0.2.0— 33 <br />Owner I\(oJCcJ LtlIStty g.-I'"(41-1Address 2 (424 gekbk <br />C-57 ContractorGiec Dlit. ill iv- Address 1 'SO li-k)k)kjc„, Ra, <br />Consultant / Sub Cntreelf430114--tamit.0?-01"01+A-1 Address O. LA. 2S9 <br />PROPERTY Coron. Del <br />City P-4et-r- Zip 9-2-4,-"Phone#(141) 7611-- 75113 <br />City,!4441 heZ., Zipci4cS-3 Lic#411C Phone# /2S-- 3i 3-- (:;8-00 <br /> Lic# Phone# 7o7 40 <br />GIS Coordinates: X , Y , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />U SOIL BORING # <br />Ail WELL # r\p, <br />a *Other <br />COMMENTS: <br />(i DESTRUCTION (choose type below) <br />II OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />CONSTRUCTION SPECIFICATIONS r.,11 <br />DIA. OF BOREHOLE 5!`. a MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: -C <br />CASING THICKNESS'* keel 4-0 TYPE OF CASING: a STEEL°S.PVC fi OTHER: <br />DEPTH OF GROUT SEAL 0: 10 ' TREMIE TYPE TO BE USED: 43 AUGERS'' fl HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 41...No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Pthitleak A 1/0: <br />O OTHER: a OTHER APPROX. BORING DEPTH N.' 3cI a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED MO (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />e-10-11-2- <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: II i 0 W. Yoser)-1;+e <br />Marri-ed,a CA <br />WORK PLAN DATED: reb rtActry 10 ) Zoo3 <br />Application Accepted ByT, Iv c a.aY+Y"Let <br />Grout Inspection By `,1.‘0,42.e..0"7&., Date 57 247 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS. Ins 41J+ ; o ir lhAd 1.41 ate / n on 440 r uj eli - M. W - 3 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQU # INVOICE <br />3 5 0I '8'1.0o 4.8 9, 0 0 , 8 0 1 R# 003(, 007 <br />Signed x <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordi . . r e1, ' , : . • • ulations, and all applicable California State Laws. <br />—.041r1; <br />Title/Company C7/Ceet40/7-- /174,04022Y" 6,6reff46. <br />Date /1 /4471/03 <br />Date Issued / - I 0 - 3 Area if 2-11-5 9 <br />Final Inspection By`714/et.eizet'lliZa,0447 Date Si 266/ <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Enr-o-achrnent doc 9/30/02 <br />