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Signed x /2-177-,-71/44 / •VS-6/4',Y Title/Company <br />Print Name 7/46” 1/64c-i-e Date /A-2-9— ° <br />SITE MITIGATION UNIT IV <br /> <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN CO= <br />ENVIRONMENTAL HEALTH DE Olgti!Tv/(Ftir <br />304 E. Weber, Third Floor, Stockton, CA., 95262 <br />(209) 468-3449 NOV 2 9 2004 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEMUED,. , , <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thit'apPfication-' ifii 4 wb,iti iidthpriance with San Joat <br />County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />r. Assessors <br />WELL Location gee) _„,/4 5. / Cross Street IP P 4 /6T76 City )70efezait/ zip Parcet# <br />m 11[64 Smite-0A/ .. <br />PROPERTY Owner 0 i-- I V A, g-Ee. Address l'`i6 iv,s6er-rs- 44/6 city Ste:A-7,1tJ zip Vsw5i.tione#1 , gls-3 <br />6si ,d/o7 <br />C-57 Contractor 64.64 4i1 -/V.---Address 9,0 '4 C) CityPievralf Zip i3-7 Licit — Phone* VS- 1/3 s-gav <br />6/111- e44.4,_ <br />Consultant I Sub Cntr 4117s-//6t- aig-A44,4-6frtr/a-- Addres/94°54e/41 4"/ Cityn"fre*W6 Lic# 5 77a7 Phone# 4174 779 <br />GIS Coordinates: X , Y , Township Range Section <br /> <br />WO,RK TO BE PERFORMED: ,- <br />*NEW WfA-L / BORING CPIJGEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />g'scm_ BORING #.-"r--Z1 7 <br />0 WELL # a *Other <br />COMMENTS: <br />g'DESTRUCTION (choose type below) <br />0 0 R-BORE. DIAMETER <br />RESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />p MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE -2 '' p MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: <br />I] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 760 (.6, TREMIE TYPE TO BE USED: g AUGERS 0 HOSE <br />0 AIR.SPARGE/ OZONE K1SH POINT (GP or CPT)GROUT SEAL PUMPED: es D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3C1'); <br />1146IL BORING 0 HAND AUGER GROUT SPECIFICATIONS ---Cil4C/v-i--- 6/-A--z,-,-- <br />a OTHER: 11 OTHER APPROX. BORING DEPTH ,/ 2 <)-- It 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE — 3 <br />CONDUCTOR CASING PROPOSED ,V0 (if YES, list specifications in comment section) ?1,- <br />COMMENTS: 1 7--74 CA/619, j"1-7 ,a---F <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 Co <br />Ordinances, Rules and Regulations, and all applicable California State Laws. C/P24.- ,4- v--v' <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 7-7_1-0 c( <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />LACCOUNTING ONLY: AID# <br />DEPARTMENT USE ONLY <br />374o S. <br />Application Accepted By Date Issued <br />Date Final Inspection By <br />Date <br />Area06f 57 <br />Date <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />3 -- (7-- 2— <br />C-57 it WC5N-P-WAIVER C-57 Letter of Authorization to sigh permitYl <br />t'q <br />9/30, <br />(4,e_ 217,0, <br />4f9K