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Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />Environmental Health Department APR 1 9 2004 SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joa I HEALI I-1 UNIT IV <br />PERMIT/SERVICES <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />an Joaquin County <br />bc.3 <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 />WELL Location 10 k 0,s+ 1 z 12 s_h_etrl- <br />PROPEXY ,,_ <br />Owner ' Vo, c; \-1 r 773.nctr- Co. Address 1 -/ 0 IN,(- ,......) PA "A t/y..1 CitySF CA Zip TitiOS- Phone# q/5 - 8 z Y- W388 <br />C-57 Contractor V I 1a)1•3 6)4 AddressilrO ActIkrNs ci 5/Itt 072Flone#5.7654M14 <br />Consultant/Sub Cntr l'IcktA3 FAVirOnMe.A-'6,1 Address <br />GIS Coordinates: X , Y , Township <br />WORK TO BE PERFORMED: <br />o NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHE <br />SOIL BORING # <br />0 WELL # <br />[] *Other <br />itDESTRUCTION (choose type below) <br />¶j PRESSURE <br />OVER-BORE. DIAMETER em <br />PRESSURE GROUT <br /> <br />GROUT SPECIFICATIONS <br /> <br />COMMENTS: <br />-t <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXI UM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS IMA.12,t <br />0 OTHER: a OTHER APPROX. BORING DEPTH <br /> ' <br />CONDUCTOR CASING PROPOSED (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 Ordi es, R les an Regulations, and all applicable California State Laws. <br />Signed x Title/Company a/yid-IL Cc?, Le, ,j-y- S&Ls,' i-5:;v1/7-4Ptimet-CAz <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br /> 16 E . 12.14- Si) <br />WORK PLAN DATED: <br />Assessors <br />Cross Street 1-1,,l(1 Te,14_ City 71-0.c.41 CA Zip qss16, Parcel# 3 3 -3 CY - 22. <br />00 ty Co4cordiA Lic# Phone# q2S- 24116 t$78 <br /> Range Section <br />TYPE OF WELL <br />ONITORING <br />a EXTRACTION <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />OLLOW STEM DIA. OF BOREHOLI I a MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />a BOLTED TRAFFIC BOX or (]STOVE PIPE <br />Date ////6-/e),ft <br />r)( 2.-005C <br />Date Issued 4-Z-1-0 4 Area 65N <br />Final Inspectio a:de PLETED Date 6- 3o- oil <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE RVICE REtit Irs. VOICE <br />3502' WI) 66. -- I 25-7-- 0,..xt kit...t sR# czn.31_601 <br />C-57 .1 WC %./-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001 <br />9/30/2002