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DEPARTMENT USE ONLY <br />$igned x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By bik <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Date Issued 5 <br />Final Inspection By <br />wr. -WAIVER C-57 Letter of Authorization to sign perm' Encroachment doc. <br />e <br />03/29/2004 12:25 <br /> <br />2094683433 <br /> <br />FIFTH FLOOR <br /> <br />PAGE 02 <br />• <br />WELL. PERMIT APPLICATION FORM <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />SAN JOAQUIN COUNTY <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application 's hebymade to San Joaquin County for D permit to construcl ancVor install the work de sbed, This application is made in compliance with San <br />Joaquin County Development Title, Chapter 1 1 5.3 and th Standards of San Joaquin County Environmental Health Department. <br />WELL Location 0 /2- W, <br />Cross Street Cihy `45/1"\-eiwt-elt Zip <br />P A.S <br />arcel# 4 <br />cv.„4_ <br />sessoek <br />Address <br />_City A f-ec 4".____LIEphone# 2.0-7 9)-3 MLR <br />c#73`0°141Ptionettlia) 71Q a <br /> <br />cA <br />Address r_210-15-1/10-..G5R —City Zip...U(1/2:1 PROPERTY Owner <br /> <br />-5,YNA.r. Address /2.P_/42.---j---2..5—'—City°46 7 phone; 9/6 996 D933 <br />C-57 <br /> <br />Section <br />Consultant I Sub Contractor <br /> <br />Range <br />GIS CoOrdinates: X . Y <br />, Township <br />DESTRUCTION (choose type below) <br />fi OVER-BORE <br />0 NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH,11AND-AUGER, OTHER') OPERFORMED: .1(pRESSURE GROUT WORK T E3E <br />0 SOIL BORING # <br />Grout Specifications. 0 WELL # <br />SITE <br />MITIGATION <br />UNIT IV <br />CoNsTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE <br />MULTIPLE CASINGS? f] Y E S 0 NO WELL CASING DIA: <br />CASING THICKNESS <br />TYPE OF CASING: D STEEL D PVC 0 OTHER. <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: i] AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br />GROUT SPECIFICATIONS: <br />APPROX, BORING DEPTH n BOLTED TRAFFIC SOX or 0 STOVE PIPE <br /> <br />CONDUCTOR CASING PROPOSED? (it YES, list specifications here): <br />NOTE: <br />'COMMENTS: <br />OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br />Ihoeurn o eaticrelfa c y theast,IRhuavleesparnegaRreegdutihaitsioanpsplaicnadtiaolni <br />applicable <br />itchaabtltehce of or k r n ai si btaetedoLnawe isn accordance with San Joaquin <br />c <br /> <br />Title/Company .6-101-(416- (CPV(r_ <br />Date <br />`Other: <br />COMMENTS: <br />TYPE OF WELL <br />fl MONITORING <br />D E)Cf RACTION <br />()VAPOR <br />fl AIR SPARGE <br />D SOIL BORING <br />0 OTHER: <br />INSTALLATION 'TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMERJORIVEN <br />O MUD ROTARY <br />1:1 PUSH POINT <br />0 HAND AUGER <br />13 OTHER