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WELL PERMIT APPLICATION RRM SITE <br />La gcEllt, <br />Iv SAN JOAQUIN COUNTY IT ENVIRONMENTAL HEALTH DEPARTMENT ( <br />304 E. Weber, Third Floor, Stockton, CA., 9E5N2v0 <br />JAN 2 8 <br />2 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS ONMENT HEALTH <br />(209) 468-3449 2005 <br />:....t <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Th s .*L I. tiSfiRVVEV compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. . <br />Assessor's <br />WELL WELL Locatio2-14 i AiAis4/ DO Oa- Cross Street i / 1-.31ity 5)&-Idioti zip , e ,.... <br /> Parcel# IC33100 G <br />PROPERTY Owner 114 -BP Address 77( 0 AK citysize,W2t6 -zip72267phone# §t-2_ Deb? <br />C-57 Contractced $ C a Pa- WA Address3k) 3 2- 0)-kRz- C4--a-CityVDCIMA2Ip 1S-W4gic# 77 754hone#a46 e:gr /769 <br /> <br />Addres6W 3 hat,,) eadCityLVoc,--4&# Phone# 46 7 ADZ, Consultant / Sub Cntr kt) <br />GIS Coordinates: X , Y , Township tion Range Sec <br />ORIGNAL <br />),-1) <br />WORK TO BE PERFORMED: <br />A'fIEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # <br />o DESTRUCTION (choose type below) 7 <br />a OVER-BORE <br />lJ PRESSURE GROUT '2_ <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 2,44•4.4 ivirYPE OF CASING: 0 'STEEL 'gPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ds:" ‘tIlt2.4.--- TREMIE TYPE TO BE USED: ,EICUGERS 0 HOSE <br />0 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOW: MAXJMUM FRE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: P °& VZ)1 c-ter.7 <br />Ii OTHER: fl OTHER APPROX. BORING DEPTH ec75- F-eatErBOLTED TRAFFIC BQX oil STOVE STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, Itst specifications here): <br />*COMMENTS: P1/4 10 \ie--e-kt_.,- 0.... 4CSV-4-7 !..A,e, <br />_ - CONSTRUCTION SPEC=IONS <br />j:VIVIONITORING XHOLLOW STEM DIA. OF BOREHOLEg UL, ,ATIPLE CASINGS? 0 MULTI-LEVEL? j] WELL CASING DIA: <br />Z tn <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x LACQ4SL, Title/Company <br /> <br />Date 7cg 7 /5 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:NLAC( Dir-fru' 2_ <br />WORK PLAN DATED: 27 ter er- zoo (-( <br />Application Accepted By Vi I+ r ;Ct L. Me 6r-14 <br />4 <br />Date Issued Feb r u 4 io zoos— Area 44-9 <br />2/ Grout Inspection By•-,‘,.e:M.47./.#4,-tio-t-e? Date -/o Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS. I 41LdiLIrx 0- kwhai+b 1-:‘ welt M W -q . <br />ACCOUNTING ONLY: AID# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! QUEST # INVOICE <br />2501 41'89.00 el cw) 2126g ,5')R 0041197 <br />Print Print Name W s)lt <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />8/29/02 <br />