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Date Issued <br /> <br />? ?C)C9-S Area <br />Final Inspection By Date <br />4 <br />Date <br />Application Accepted By <br />Grout Inspection By -.l- - . - <br />Destruction Inspection By( ' 0 <br />COMMENTS / CONDITIONS: n44i ix <br />_ <br />Date <br />‘1411 <br />Joaquin County parr, i vFP <br />Environmental Health Departm( - SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 2 7 no5 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orOeHoi UNIT IV <br />Well Permit Application <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 com lianca_witla-San ,-,‘ <br />EtfilROmtNIMENE;\HZELsT,ck <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS D <br />(-1-: , F i.i.,-., 01 'LI 6 Z c) .6fr, c ed ers-nc Assesso <br />Joaquin County Development Title, Chppter 9-1115.3 and the Standards of San Joaquin County Environmental Health D..nartment. <br />i 7 <br />WELL Location 1A 1"trel7 * .6. SAW& f4Ping7 . Cross Street la. L./L3 .-153JitY t. - Zip-6m Parcel# <br />PROPERTY ii'- Li' is ki cc -t,_ g d i,Gi5,:d <br />Owner Mith24/ 1 Oe.-it t)--5 Address "R174-4.g----tki}- City Zip 024e Phone* 4'7° 611 el U6 3 <br />C-57 Contractor (-7-ar....),,, /A- /,,, Address --/: 7 6 1A.A1 n vl 4ity '-:,,$441 lgui If /c# ‘_5. hone# 5C 2 923- ig `i (i <br />Consultant / Sub Cntr 0.1e, P.14kg -.E14q- P Z- Address 61 /4) MI Velf2f-.'.'City A...A-4;14./ Lic# C -21, 2 lc; Phone# S3,-",t32-3 Z"( <br />GIS Coordinates:). e.:_-.:424/lio e , Y /4?.."'el0 Ai , Township 4 N4 Range -7 -- E Section 3 I <br />WORK TO BE PERFORMED: <br />o NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />U SOIL BORING # <br />WELL # <br />ff*Other y <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING D HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />fl EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS "'"fi TYPE OF CASING: fl STEEL a PVC a OTHER: <br />fi VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS g HOSE <br />El AIR SPARGE/ OZONE *USN POINT (GP or CPT)GROUT SEAL PUMPED: Ii Yes II No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />g SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />g OTHER: a OTHER BOLTED TRAFFIC BOX or STOVE PIPE APPROX. BORING DEPTH 647 L;tK:..) Ft <br />CONDUCTOR CASING PROPOSED (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 />Signed x Title/Company /2(e5 .2'9 2 i° /9.4peot F-R <br />Print Name ./.2 -1-7/ /77- 77/4-31-77)\ <br /> <br />Date 6 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />O OVER-BORE. DIAMETER <br />If PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />ACCOUNTING ONLY: AID# FAC,# <br />J <br />PE CODES FEE INFO AMOUNT REMITTED CHECK I/ REVD BY DATE INVOICE RMIT I SERVICE R /I i <br />g-Adi 6/iVo.i smit.04/- Z g - <br />C-57 WC -WAIVER C-57 Letter of Author4ailion o sign permit Encroac ment doc <br /> <br />EHD 29-02-001 <br />6/22/04