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TYPE OF WELL <br />"ilMONITORING <br />[] EXTRACTION <br />[] VAPOR <br />[] AIR SPARGE/ OZONE <br />[] SOIL BORING <br />[] OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S" [] MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: 7-1/ <br />CASING THICKNESS Sc-C... 1 TYPE OF CASING: [] STEEL :{1. PVC u OTHER: <br />DEPTH OF GROUT SEAL --.5 1 TREMIE TYPE TO BE USED: AAUGERS 0 HOSE <br />[] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: -,8 Yes [] No (NOTE: MAXIMUM !BEE-FALL DEPTH 1S30') <br />[] HAND AUGER GROUT SPECIFICATIONS 'P.,--4(q.-id cury-pLm --4 &-r <br />[] OTHER APPROX. BORING DEPTH '16' , 0 BOLTED TRAFFIC BOX or [] STOVE PIPE <br />?ONDUCTDR CASING PROPOSED /1',/-1. (if YES, list specifications in comment section <br />t.•\ e_.0.1 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />cce <br />INSTALLATION TYPE <br />'HOLLOW STEM <br />[] AIR HAMMER/DRIVEN <br />[] MUD ROTARY <br />-10 <br />9) <br />CA 0 SAN JOAQUIN COUNTY <br />7 WEAERMIT APPLICATION ARM <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> <br />JAN 2 0 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMEN1 HE,ALTH <br />(209) 468-3449 <br /> <br />PERMIT/SE71CL'S 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 ec 1::).A.,;-N-c Ave.ncet.. Cross Street 17:1,t-.1e..t-- Ave_ City Zip??el#5",-/ Parc OT) ) <br />PROPERTY Owner /vIa.,--&21, te '-Address AL-0— Zipq5 ac/9 Phone#2.0(1 'IS I -6 <br />C-57 Contractor h‘-,.11,-fl Address 9S0 Yod_kie P.-d. City A4(tkrqirlt)- ZIP S Lic# L/85166 PhoneitqZ_S <br />Consultant / Sub Cntr 0... <br />GIS Coordinates: X AIM , Y <br />WORK TO BE PERFORMED: <br />ft NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER-BORE. DIAMETER <br />-1] WELL # ' El PRESSURE GROUT <br />[] *Other <br />COMMENTS: <br />REC SITE <br />MITIGATION <br />UNIT IV <br />Address ?--qc) ols S-A-44.4 City Lic# NkG 6tz4 Phone# (_14 ct3S-t-res.-5=, <br /> <br />, Township A/f,4 <br /> <br />Section tv7.1 <br /> <br />GROUT SPECIFICATIONS <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 d Regulations, and all applicable California State Laws. <br />Title/Company 9,w/wife/Lc /770,,v6e/apee a, #,,a, <br />Date /1/11-10 <br />DEPARTMENT USE ONLY <br />-5 <br />SITE MAP IN UNIT IV FILE, <br />ACI.3 0 <br />DRESS: E,G31 CiAA A Sir tic-4t <br />WORK PLAN DATED: 10 <br />, <br />Application Accepted By (Arvvv‘e f•N Date Issued <br />Grout Inspection By LI-11A4Acet-1 Date '24 I Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />----, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER - • INVOICE <br />SR# 3 Li <br />Signed x <br />Print Name <br />Are- <br />Date -2- (C o / <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />9/30/02 <br />