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Date <br />Date Issued <br />nal Inspection By <br />WORK PLAN DATED;1 <br />I 1.4 4 /Atteliker" 7 • <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />San Joaquin County <br />SITE <br />MITIGATION <br />UNIT IV <br />2005 MAY 20 PM 12: 26 <br />-h ,COUNTY `-• .. AU•..,,, <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliatircarftiRmisajiltrapith San ‘ <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Dei <br />5D5 1, <br />nA <br />T1 E. rfDik1-ittle- 0 (ft Cross Street 0-0 i a ii City <br />zip 67152,1 itilAAfter psaDsrceeEsIsPooArsoROT5r.MAitE N3T..0,7.. <br />4f . ti <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: rEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />El SOIL BORING # <br />")31,WELL # 1 <br />U *Other <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> <br />, l I <br />)(HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: e:- <br />I] AIR HAMMER/DRIVEN CASING THICKNESSqlt . q 0 TYPE OF CASING: a STEEL XVC a OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL" 170 i" TREMIE TYPE TO BE USED: 0 AUGERS .HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />1:1 HAND AUGER GROUT SPECIFICATIONS Pol-t-tift.kt dr1. <br />1:1 OTHER APPROX. BORING DEPTH eiu )030LTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED rip (if YES, list specifications in comment section) <br />COMMENTS: <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 />1 <br />Signed x f+LA.A.C4._ (A., Title/Company S14 (00 / ACIVAR.Cd1/4 061W CCIAWIJAA <br />Print Name cc...Am_ L. Date 5/7.--0/0 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <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 />WELL Locationt <br />IL <br />,j 1 <br />OPRwOnePrERTym kocks <br /> Address 15 %17 voila- vd City ?1.91,1kCi.741 Zip115100 Phone#(70q)*'/I6D <br />C-57 Contractor M1h,14e11 1C-11\116‘3). Address --mbo Ali fil Age, City 6 rata Zip (503 Lic# b1107 Phone# 1701) 4411-.110 k <br />Consultant / Sub Cntr A elL Address '..S..7 Stutt.t.td a City Sili Olik Li c# CoRO227 Phone* (....1:041 LW/ -(vot <br />o OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />)(MONITORING <br />a EXTRACTION <br />U VAPOR <br />U AIR SPARGE/ OZONE <br />U SOIL BORING <br />13 OTHER: <br />ACCOUNTING ONLY: <br />s _ <br />AID# FAC# "S-R 0 f) licf2 41 `3 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY <br />% <br />DATE PERMIT / S -, - • EST # INVOICE <br />-.)50 '3 ( , CO fl -7,-, , . _ / ,,,, / Ve -' sR# 4-z Lt 3ti <br />C-57 WC -WAIVER_ C-57 Letter of Authotgz74 <br />El-ID 29-02-001 <br />6/22/04 <br />to sign permit Encroachment doc