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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />9)- <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued Area (CV <br />Date Final Inspection By Date 6.10,05 <br />Date <br />COMMENTS / CONDITIONS: <br />ROIVIENT v21-1161:EAN8Li P.DE:MCIT -1/P:R <br />MITIGATION <br />liTi 01V <br />ENVIN <br />i\T <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 16130 Ce...-^---6c:dy Si . Cross Street J-I.--', City Le,-{-k-t, Zip /52_?C; Parcel# ii'Co .930 - 32_ ,- - <br />Owner <br />P b6ah MidiAdd ress1.17-11;06 5 . teeastd City ,Zip Phone# ,.., <br />PROPE -' <br />J <br />C-57 Contractor 14,45ctu.9.--Cc\ Okr11%)C.0 Address ..CSO Z.1,-)e c- i2d, City TZ`J 1-1 :4-ct Zip/1/57-1 Lic# 7/e0-c Phone:4'7<VA 3 J-1 - 20a, <br />Consultant/Sub Cntr 5er tot- -trcl . , LIL Address 300- /2.' ofr 7-fl.,*• icX3City colif,a Lic# Phone# rie2;\ 86, I - 010(2i <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 # <br />OVER-BORE. DIAMETER <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.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />ORIGINAL <br />SITE <br />LI WELL # <br />O *Other <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />— <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE I S a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: -4 <br />a EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL ° PVC a OTHER: C) <br />0 VAPOR 0 MUD ROTARy,--N;‘,, DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ['AUGERS p HOSE Q a AIR SPARGE/ OZONEI(PUSH POINcl((GP,Or CPT)GROUT SEAL PUMPED: H.Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />D.SOIL BORING a HAND AUGER--". GROUT SPECIFICATIONS .'Jet-* c„,.........._4 Is <br />° OTHER: 0 OTHER APPROX. BORING DEPTH 70° a BOLTED TRAFFIC BOX or 0 STOVE PIPE ..n • <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) -1. <br />COMMENTS: 9-- <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. 1 <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 Ordina es, Rules and Regulations, and all applicable California State Laws. <br />Signed x 11 1(5 Title/Company S'kk--(2C- 1.5÷ Ez 2_ 24, <br />Print Name /0,-41 k"..) 11 4. Date i 2 <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE QUEST # INVOICE <br />6:O7Zq-3 CR,-' sR# 00 4,01 r----, , <br />COMMENTS: <br />C-57 Letter of Authorization to sign permit V( Encroachment cro-r -WAIVER <br />EHD 29-02-001 <br />6/22/04