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Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE lig4AUG I I PH 3: 54 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work des id. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County EnvironntnIfltsMIM D_e(Satttopint. y <br />- _t 12p4 Assessors WELL Location goo gip& .wilsonwcui Cross Street L1,(5+- ICI kCity Ft 'fr.! rarcel# <br />PROPERTY/if _ <br />Owner .4 i2tGek PO gat.) Address 31- 5 Ni iaerado City 5ifY01 Zip 9c70/Phone# gm) 93?-J4? <br />C-57 Contracto <br />San Joaquin County <br />EL :onmental Health Departmei <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 />16prAnDnik5.7ifok, Address 9co 1--kwe i2Old city41-4)(12 zipwg egoo7phonet(9.2.03a-seeez• <br />Consultant / Sub Cntr EXOEAVAddress g_.3 7 <la° citySiOdAN Lidt 6902 7 Phone# <br />GIS Coordinates: X Township Range Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />fl WELL # <br />KOther 12r <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE .2 " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DI'-314 <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 4///1+ TYPE OF CASING: a STEEL a PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL F'_/14--ive TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />0 AIR SPARGE/ OZONE RUSH POINT (GP or CPT)GROUT SEAL PUMPED: A Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />ykSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS p 01 H / A • t e. i C11 4 4011.' £1.-- <br />a OTHER: ,,,n • APPROX. BORING DEPTH /z./v a BOLTED TRAFFIC BOX or a STOVE PIPE 0 OTHER <br />CONDUCTOR CASING PROPOSED 41v (if YES, list specifi5,ations in comment section) <br />COMMENTS: i fibir <br />y <br />e.0 A44, t lipb 60 r 1115 (' •e_a_e- in (7 PT tr,e_ 4 I-1 00 ( i <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 />IL-at S / Mu oA di elGi ceE3A-0 Signed x Title/Company <br />Date (;// 0 ID <br />SITE <br />MITIGATION <br />UNIT IV <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE, DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Print Name Name N; 1--(1 K0t) SAA.100t( <br />DEPARTMENT USE ONLY <br />Date Issued Pi, ZOO-) Area / <br />Final Inspection By Date .2_/1 /6 <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />, PERP.51.,0_11VICE,EQUEST # INVOICE <br />-* 3 g 1 6 3 --7- : <br />C-57 Letter of Authori/at -to sign permi croachtuatdoc (an <br />/ / <br />...../- <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04