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i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Orrnances, Rules and Regulations and all applicable California State ws. <br />Signed x <br />Print Name <br />Title/Company <br />Date 7 <br />Application Accepted By V i ; Mce_a r -frivati Date Issued <br />Grout Inspection By /'(7,-grq,z,0 -17/e.6,41/7 -1.4.7 Date <br />Date <br />A dlin e.c. a4d 4tit e g_, 0: hoc; 5 <br />.20041 ul 2Z Area /25-q <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Final Inspection By Ae.-/Y.?l,st,-- . //14 te gi 3/ OX <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ehd <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 />Assessois ,a7o2 004 <br />WELL Location I ti 366 (II/ 41 / Cross Street 99 City IYM.4 te (a_ zip l'S-3be Pa rcel# ' -I <br />Ownert.t_4,1 )Thr6 (A.A44 Lt..,c-v Address 49' 0, t5W-A/010-7 City 9thrk Zip5co20/Phone# (,20q)Yb' 5 - 3g .2 ( PROPERTY I 4,i , f \ „, , O.-. (- <br />Address 3''7 5},a,44.) pil City5Pda" Zip5c.:GS-1/ Lic#4 Fla4717hone# 02o9 %7 -i6dt, C-57 Contractor fr.ble <br />Consultant / Sub Cntr 5CtA/V\--11-- Address City Lic# Phone# <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />'NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />SOIL BORING # 3 a OVER-BORE. DIAMETER <br />ELL # 0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE L2c1:1 MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS /VA_ TYPE OF CASING: a STEEL 1:1 PVC fl OTHER: <br />DEPTH OF GROUT SEAL 1-7D TREMIE TYPE TO BE USED: U AUGERS fl HOSE <br />AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PLAIPED: 13 Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />) <br />1,SOIL BORING <br /> <br /> HAND AUGER GROUT SPECIFICATIONS <br />OTHER: fl OTHER APPROX. BORING DEPTH BOL BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT CR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />SITE <br />MITIGATION <br />UNIT IV <br />CI) <br />*Other <br />TYPE OF WELL <br />MONITORING <br />fl EXTRACTION <br />g VAPOR <br />INSTALLATION TYPE <br />fl HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />1:1 MUD ROTARY <br />AF 'C <br />-P o(tlo-,GN <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ) 48 0 O 14 A y) wd ,„ cpq <br />WORK PLAN DATED: N em he,e. 1 8 )1.2. o03" <br />Mart -feda CA <br /> <br />ACCOUNTING ONLY. AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT/SERVICE RUES1#INVOICE <br />3501 *99.00 v g9. 0 0 Zb74.8 ( sR# 0 0 3 8 s 8 3 ) <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permi <br /> <br />EHD 29-02-001 <br />9/30/2002 <br />