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WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />I-SOIL BORING # G <br />1] WELL # <br />El *Other <br />CCOMMENTS: Atrove..- (4.41.46 <br />GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) ['DESTRUCTION (choose type below) <br />2142 ) SG - OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />"6.0/1- $Y" itede addee_44-( ..zyW 6; kast4014 (•4-s :000 '9 San Joaquin County <br />Environmental Health Departma <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd MAY 1 1 2 005UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENI HEALT -i <br />PERMIT/SERVICES <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 compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Locatio <br />.•••• LiA A. <br />-u\ <br />, AssessoN , <br />Cross Street ef--th _ . City 56ckl-Lry) Zip ri c'2.-1/2-- Pamel# i W-2(10Z 3 n .2,y -ra G- i <br />t 5i4; fe' 'La.1 City S .L..., , Owner 9c ,,,,.‘4 L i.---7 . airnokAmi Address 2_3-C-1 . FrfaKal+ ., s i ,,r. K. i-tW1 Zip cr5.2-03- Phone# (4.0.0Ci) (-1(,0 3-- SS-621 <br />C-57 Contractor 6rRty3 T- 1,1 Si444. Address ci 51) t4n/)e... CLCi- CityAtVityttl Zip CI Y553Lic# C'",-6 4 hone# ( q 2-5) 36-513a, <br />Consultant / Sub Cntr 61.21,44 EI elvt fidtViCoAtkvevCi4ddress 270 Pe eir-i. ti 5 Si city 1CyWhA. Lic# Phone# <br />GIS Coordinates: X , Y Township \ <br /> <br />Range Co E Section <br /> <br />4 [SITE <br />MITIGATION CP/ <br />PROPERTY 7).95(4--‘"" cwu-t l'o"-(11 <br />(?-0-9-) 9 3s- - <br />TREMIE TYPE TO BE USED: 0 AUNe bc)'00 <br />PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0..Yes fi No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS LLL.k(3X-CA-A--k <br />0 OTHER APPROX. BORING DEPTH 615-- BOLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED 0 (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. i ir -L <br />Signed x 26 Cf—f& Title/Company , p cr(L -hc-An ka-41L0-61--- <br />c1-1 at/(1 (k) - <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLANPLAN DATED: e—_%1 -0(-( <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />fl AIR SPARGE/ OZONE <br />-SOIL BORING <br />fl OTHER: <br />Print Name <br />INSTALLATION TYPE <br />fl HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE -72-: 0 MULTIPLE CASINGS [:1 MULTI-LEVEL WELL CASING DIA: VA -P. <br />CASING THICKNESS ''',//A TYPE OF CASING: fl STEEL 0 PVC fl OTHER: <br />DEPTH OF GROUT SEAL <br />Date '31i IC <br />Date Issued /0 <br />Final Inspection By <br />06 (NI Area Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS. <br />Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY <br />-m <br />DATE <br />----. <br />INVOICE T/ SERVICE <br />'() 1 <br />---- <br />. -)'-, (;-?D 1 'r --) • (--A-Y- sR# 00v9,-zie ) <br />C-57 v WC V -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit/IØ Encrpachment doc <br />"1"cee- C-17 ctree...-4--W -444 EHD 29-02-001 <br />9/30/2003 <br />