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SITE MAP IN UNIT IV FILE, ADDR <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />2.31-5 A I <br /> 4e-ea <br />6X-D <br />* <br />"1.44/11:40:11 <br />Final Inspection By <br />Area UW Date Issued <br />Date <br />Date <br />V062U-E <br /> <br />ORIGINAL San Joaquin County <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 /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />Application pplication 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 />i Assessors i <br />b <br /> tap', 2 <br />WELL Location 23 0, 6 't 1F; S-t Cross Street r , AJE City -.7.0C i4-7-0 1\-/ Zip 757-&,--t Parcel# l-70 vitt <br />PROPERTY <br />Owner VINt T , 194-2TNe4eleAddress2326) /4 ' 6111- (6 c>e 4- City S. 7:7K TON Zip 73-76/1/Phone#Zo :I 146(e) Z 0-00 <br />C-57 Contractor Q1664-(1--- itt/S 17•0 Address 9:57-2 HerCti6 ID CitPhrtTliA/61Zipti/V5-53 Lic# 65(ø407Phone# c/os- 3i3 COC6 <br />E C gic24,6 <br />Consultant ub Cntr Address "4'47 City"764-4 Lic# 5 770-7 Phone# IV& 7? S-7 <br />A <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING <br />U SOIL BORING # <br />a WELL # <br />COMMENTS: <br />FAT *Other C. P <br />GEOPROBE. HYDROPUNCH, HAND-AUGER, OTHER*) )DESTRUCTION (choose type below) <br />U OVER-BORE. DIAMETER <br />0.,PRESSURE GROUT <br />"ROUT SPECIFICATIONS 57 -6/0 ,9el-e 14 0 PE---4 <br />3 TYPE OF WELL <br />a MONITORING <br />O EXTRACTION <br />O VAPOR <br />O AIR SPARGE/ OZONE <br />'?(SOIL BORING <br />a OTHER: <br />INSTALLATION TYPE <br />a HOLLOW STEM <br />El AIR HAMMER/DRIVEN <br />o MUD ROTARY <br />USH POINT (GP o <br />O HAND AUGER <br />El OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2-'1 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL p PVC a OTHER: <br />DEPTH OF GROUT SEAL Ft-AA-Peg' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />GROUT SPECIFICATIONS /0ge"-Ixs- /-77. r/Z, Ate* <br />APPROX. BORING DEPTH f2' ['BOLTED TRAFFIC BOX or a STOVE PIPE <br />GROUT SEAL PUMPED: ;If 'Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />e-A NE la 5 C-49 7- -A- j ACize),, 5-7/-e-er 44-/A/14 <br />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, R les and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name /6-7/M----6- 1/4- 4 c A-1 <br />COMMENTS: Vc U <br />NOTE: <br />e4/4 /rt/6-6--Z - <br />Date /) '9 5-- <br />-- ------ --- - - - - - - <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE . - . z EQUEST # INVOICE <br />-87 ,---- <br />Ott. 10/7 SR# (9 p OM b <br />C-5747 WC 7-WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit <br />