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WORK TO BE PERFORMED: <br />o NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />fl SOIL BORING # <br />fl WELL # <br />fl *Other <br />COMMENTS: <br />XDESTRUCTION (choose type below) fW1445 <br />,,OVER-BORE. DIAMETER /' /' Alt -.2 Atui4k,r-9- <br />n PRESSURE GROUT GROUT SPECIFICATIONS <br />7 G 5 70/1- //k// ,/77/// i/iM/— 2_ <br />TYPE OF WELL <br />XMONITORING <br />a EXTRACTION <br />a VAPOR <br />INSTALLATION TYPE 04.20_sino_ <br />a AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />Application Accepted By <br />Grout Inspection By <br />Area <br />Date 7--/Z-S/C25-- Final Inspection By 51/45 IC( Date <br />z." Date Issued <br />n Joaquin County <br />nvironmental Health Department <br />c:r:qof E5110,1,9.5ber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ENVIRONMENT FlUt_TH <br />PERMIT/SERVI ii Permit Application M <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 . WELL Location ‘/eVA/Ath`f gy/poir Cross Street P44440 ‘44/ECity f 1;0 eA" reW Zip Parcel# <br />PROPERTv <br />Owner cx.,,,k vt Vi k fiCp4Z-1 iteo5ddress "TfDtp LA"-t-V/e..“ (.4.1 City5ITLciar2aZip Y5215-Phone# <br />, <br />c-57 contractor 6- Acr/morfailoAelh5 Add ress 9s90 e-404,7y emo fid C i ty 1,4,0414 cif zip e_Ws7L ,97.,, <br />phon1:1- <br />1v0 <br />12Vere:r <br />59 <br /> 7 i" *d <br />Section <br />Consultant / Sub Cntr J.e11141 rA'7; -r"; Address 10/7 ,17 /604" ,fDi e. City ce.00Pk4 Lic# 44 44 Pr Phone# g/A,47/- ei• x 2 <br />GIS Coordinates: X , Township Ran ge <br /> <br />4,1 <br />((% <br />SITE <br />MITIGATION <br />UNIT IV <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE a MULTIPLE CASINGS [l MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL [l PVC [l OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: fl AUGERS fl HOSE <br />U AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O SOIL BORING a HAND AUGER GROUT SPECIFICATIONS /f/e-dr 4-L`;41,e4/7- <br />a OTHER: OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: I VVI.1A/1 V-12 (;) fr)tAA-- <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 <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />) PP" '/Y7 <br />Signed x Title/Company 1.6(.6'41 76.40.1rICW/P/2 Zee; <br />Date • eiV° Print Name l'iih•-07471%';.-- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ( •• I-( <br />WORK PLAN DATED: r <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: Lyhe 14->ic ez <br /> <br />LI 'Lt. h y 1 <br /> <br />ACCOUNTING ONLY: AID# FAC# 6'7"Rt90 41 0 -5 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3 5-0-2- If‘C ( 0 0 ()Oti'S 1.J 'Liz >los- SR# Lk <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04