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TYPE OF <br />.oklIONITORING <br />U EXTRAcTION <br />U VAPOR <br />U AIR SPARGE/ OZONE <br />U SOIL BORING <br />OTHER <br />COMMENT/S: <br />INSTAIJ.A/ION TY_Pe cON/TRUCTION <br />u HOLLOW STEM OR. OF BOREHOLE n MULTIPLE CASIN <br />CASING THICKNESS <br /> <br />MUD ROTARY DEPTH OF GROUT SEAL <br />n PUSH POINT (GP or CPT)GROUT SEAL PUMPED: fl Yes 13 <br /> <br />11 HAND AUGER GROUT SPECIFICATIONS <br />APPROX, BORING DEPTH <br />CONDUCTOR CASING PROPOSED <br /> fl OTHER <br />(.1 AIR HAMMER/DRIVEN GS a MULTI-LEVEL WELL CASINGDIA <br />TYPE OF CASING: fl STEEL 1:1 PVC II OTHER: <br />TREMIE TYPE TO BE USED UALJGERS n HOSE No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U BOLTED TRAFFIC Box or a STOVE PIPE <br />CU YES, list specifications in COMI118nt ection) <br /> Date <br />Destruction I napectioi-By e_to' <br />COMMENTS / CONDrnONS: <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout InSPection By <br />AO. <br />,Ataa <br />Date <br />41•••••••1 .1, <br /> Data Issued 3I/° <br />Final Inspection By <br />Date <br />FACti <br />ACCOUNTING ONLY; AID# <br />DATE REVD BY PE Cobs FEE INFO AMOUNT REMITTED <br />PERMIT/SE' OUEsT INVOICE <br />C-57 WC -WAIVER C-57 Letter of Author zation to sign permit <br />Et-OD-02-001 <br />6/22/o4 <br />nc oC <br />CHECK* <br /> Title/Company <br />DEPARTMENT USE ONLY <br />iv.00 PAA 114OZWRI60 <br />ClftYt OR_GrPLA RECEN <br /> <br /> MAR 8 - 1005 <br />Well Permit Application <br />NoN-REFuNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby mode to San Joaquin County for a permit to construct Lid/or Install the WOrk described. This applcalion <br />i3 made in compllence with San Joaquin County Development 11110. Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br />WELL Location _2 7 ii Aia 0 ,4e Crass Street it4,44'7rJek_CIty Sirticleel zip IS2 0 0 Parcel* <br />, Aasessore <br />PROPERTY <br />() <br />Owner Pfigr oF" frt'grooV Addreas 2201 104 I./41W rail ity.,04...cv-e3#4 zipqs_:€6_phorn, q7 " C-57 Contractor dreas R.ocj city Atorie2 244S.13 Lic#5_P hone dr/•/ - es*? Consultant / Sub cntryosi gatviii'llettl)er-AddressiSAT.,A14c-444 ir a k•••/. CityGri#0.1crf Lic# Piz 1,027 Phone:Eli - ois Coordinates: X Y Township Range Section <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 County Ordinances, ul a Rr1 ations, and all upplIcable California State Laws. <br />Signed x <br />Print Name <br />San Joaquin County <br />Deprt <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />vHicEAES <br />SITE <br />LI4 Environmental Health atneE;EIRR°mITM/sENERT <br />MITIGATION (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/eM UNIT IV <br />WORK TO OE PERFORMED: <br />NEW WELL / BORING (CPT, oEOPRoaE, HYDROPUNCH, HAND-AUGER, oTHER*) VvEESTRUCTION (choolse type bckm fl SOIL BORING <br />R-BORE DIAMETER 41.2_< ,co WELL aa 'Other PRESsURE GROUT <br />GROUT SPECiFICATIONS COMMENTS: ZI.rEektiej2_,&1Ap__ ja.F7&&4_e4424,./e2 merlt1 Alt" I 2 04- <br />39Vd 9NI11Ien 993eI9 NEOETESZ6 SO:ST 9OK/170/60