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SITE <br />MITIGATION <br />UNIT IV <br /> Date Issued <br />Final Inspec • <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />I have I hereby certi <br />County <br />prepared this application and that the work will be done in accordance with San Joaquin <br />RuJations, and all applicable California State Laws. <br />Ckt..sfa pAer <br />DEPARTMENT USE ONLY <br />5 /5" 510 <br />Signed x <br />Print Name <br /> Title/Company Akyeekt Far- awl <br />Date <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRVS: <br />WORK PLAN DATED: <br />1 Date '269 '- <br />ORIGINAL <br />LNVii-iuNorid.1 I I--ILALTH <br />PERMIT/SERVICES <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 />VE _D) <br />APR 2 6 2004 <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 l5 ()5 7 t i Cross Street L S-1" City t. a +1V-0 ? Zip 'I'53 30 Parcel* <br />PROPERTY <br />Owner .6,enC‘ Address 15 820 5 i-Iur kan 31 City L...-160? Zip 75-330 Phone# 932 - 147 <br />C-57 Contractor CetS 11;nj Address 3C23Z Oriec Cr City ..4,41.-Tcj °/, Zip ..57"/Z.Lic# 7175/C) Phone# 9/6 - £.3 / 1 <br />Consultant / Sub Cntr ASuo,nceS Geo EnV ro Address 8 37 s City $f.. Lic# (.80a:21 Phone# i145V3-41(.7-/004 <br />GIS Coordinates: X Y Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />a NEW WELL! BORING <br />SOIL BORING # <br />WELL # <br />a *Other <br />COMMENTS: ridie, <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) cpPDESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />tRESSURE GROUT <br />ROUT SPECIFICATIONS ?Orit4C.ft <br />Con-SAT:kJ c.4,e <br />T -\1 Lie // .per reguest ) New <br />TYPE OF WELL <br />cfgLIONITORING <br />0 EXTRACTION <br />VAPOR <br />AIR SPARGE/ OZONE <br />0 SOIL BORING <br />a OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a HOLLOW STEM DIA. OF BOREHOL ri MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br />El MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />U PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS ,,N t ? 01.)041347e- <br />a OTHER APPROX. BORING DEPTH -3U +' I .., a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />ACCOUNTING ONLY: AID# <br />. <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMIT / SERVIC - # <br />35C1 ' VOI (ob."- 2A)2M CIA: 0 sR# 603/-76) <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />9/30/02 <br /> <br />te,/k•itoo- <br />