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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />ued net Area - <br />IMPAIMPrFinal Inspection By Date <br />CA <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 of San Joaquin ounty Environmental Health Department. <br />- Assessors <br />WELL Location tt-t4.2 S Tracii BIQ(k Cross Street City SI-Dig:MIA) zip 4/52-C6 Parcel* <br />Address 15-q06 3 i WC/ Pki City AA-1M Zip 4`.-2do Phone* lit Z -1027- <br />Owner ERTY BC 15 ‘' kviAaAtl <br />C-57 Contractor ;i-eAttl `1) k-\ Lit5 Address NA'S (4-2.7-0 City-ItiaLD ai`draip 151;10 Licit C176 11 Phone* <br />Phone# i i127 -/06 4, <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) 0 DESTRUCTION (choose type below) <br />['SOIL BORING # 11 OVER-BORE. DIAMETER <br />7WELL # a PRESSURE GROUT <br />a -Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />A'MONITORING Alf-iOLLOW STEM DIA. OF BOREHOLE g # a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 22 <br />• <br />0 EXTRACTION I] AIR HAMMER/DRIVEN CASING THICKNESS 5(14ed go TYPE OF CASING: 0 STEEL ?<PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 61 TREMIE TYPE TO BE USED: ;AUGERS 0 HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: B Yes /No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING ti HAND AUGER GROUT SPECIFICATIONS Po (14 ,,,,,U ao <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 2-S' %BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (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 />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 4tj 1J2AA1 14A.--404 Title/Company StaCf eiCir434/Ac <br />- <br />Print Name feAkQ--- I_ • P:tv_x" Date 03/04 <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AID* FAC* 5R 003 iiitr) <br />INVOICE <br />AMOUNT REMITTED CHECK # R 'D B DATE P - e 4 .... # <br />PE CODES FEE INFO <br />356 1 • . 0 a zo ( 3 _...4 - <br />sR# 37 _3 <br />0/1(1/02 <br />SITE <br />MITIGATION <br />UNIT IV <br />Consultant / Sub Cntr Act,,Aiceo era; 6thrie-M/O1iti Sni S Ckai al City 5/Dt-k-kk Lit:* 6077 7 <br />GIS Coordinates: X , Y ,Township Range Section <br />C-57 WC -WAIVER C-57 Letter of Aut zo o sign permi <br />