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Range Section <br />a DESTRUCTION (choose type below) <br /> <br />a OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br /> <br />GROUT SPECIFICATIONS <br />‘s\ <br />ORIGINAL <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 15 (9)5 71k Cross Street L s--t- City La liNt'ci ? Zip 9.53 3 0 Parcel# <br />PROPERTY <br />Owner L. 4,151-i-en Address IS 810 S. 44e.r et^ •S' 31 City 1.4.4kro? Zip F53340 Phone# 91 - )I'1 7 36,fneS, <br />C-57 Contractor C4S ca.Jt Ai Address 3(03Z °MCC_ Cr City Czir k Zip Y,)-7e1Z_Lic# 717StO Phone# 9/6 - e, 3 t <br />Consultant / Sub Cntr AeLifuecO GeoEnv:ro Address 837 S)N c.,.....) City s-r-K- Lic# toga <br />1E:CE'VE.1 <br />APR 2 6 2004 <br />EN\h'ioNab\i-i• HEALTH <br />PFPMIT/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 />SITE <br />MITIGATION <br />UNIT IV <br />Alba/ Attid <br />3.41.;frlo <br />Phone# <br />GIS Coordinates: X Y Township <br />WORK TO BE PERFORMED: <br />A,NEW WELL! BORING <br />El SOIL BORING # <br /># 1,1 VJ -`6 <br />a 'Other <br />COMMENTS: in oue e k Fo r <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />C011 ;or% <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> <br />MONITORING W.L-IOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: /' <br />EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL CKPVC a OTHER: <br />fl VAPOR a MUD ROTARY DEPTH OF GROUT SEAL /8 TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />AIR SPARGE1 OZONE U PUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes %No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS ?or-V \G.vc0 Cement <br />a OTHER: a OTHER APPROX. BORING DEPTH 30 \go CLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED A) 0 (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 I have prep ed this application and that the work will be done in accordance with San Joaquin <br />County s, and all applicable California State Laws. <br />Title/Company AtrA4- Co r Ah Uo-"Lej Geo E et uk roe\ Men--1-6. Signed x <br />Print Na CV,r;s4-6 (1.0tr Date 2 L -0 LI <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /56/5 -S • <br />WORK PLAN DATED: 1-&?--0 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />Date Final Inspectio <br />Date <br />1, D Date77.74 <br />30 '0 Date Issued <br />ACCOUNTING ONLY. AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY INVOICE DATE ICE REQU # <br />W-0 I WA/ gct ,---- -2_02_2 5 <br />C-57 WC -WAIVER C-57 Letter of Author -zation to sign permit <br /> <br />9/30/02 AG ,A <br />