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NOV. 7.2035 <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ LI.DP 47 (/.5 (4.)• S4c4Al-:*"-17 <br />WORK PLAN DATED: (0 - OS <br />Date <br />Del <br />COMMENTS / CONDITIONS: <br />Application Accepted By <br />Grout inspection By <br />Destruction Inspection By <br /> Date Issued <br /> <br />Final inspection , <br /> •••••••••••• <br />8:52AM APEX ENVIROTECH,INC. <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stocktou, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www,sjgov.orgiehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliastion 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 Location tk?\ L _ Cross Street[/0. &Apo-Slaw 1-oa Zip S22.Parcel# <br />, Assessors <br />PROPEROwrir-11444f /a/A <br />tuAL-1-0" - (-vv. Address °/(' riTinei;feWCItyr effelli Zip ehone# 47.3057- <br />C-57 Contractor CaliC6A9-.1 \ii,\VIT-X.‘"Address 30-32. 0 rvket- I1O cirytnyliz:_(41-,1544f2.Lic$313510Phono 9fir63?-1/0. <br />Consultant/Sub Cntr X C.;.4.\\,Ntta11111("Address A2141 I2:?S Wk.) CItyG4AKEVer LIcri .#1gne# <br /> , GIS Coordinates: X Township Range Section <br />NO.ORIGMAL <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE P5RFORMED: <br />VtIEW WELL / BORING (CPT, GEOPROBE. HYDROPUNCH, HAND-AUGER, OTHER') u DESTRUCTION (choose type below) <br />U SOIL BORING # a OVER-BORE, DIAMETER <br />ZitNELL # At1/0-cflt Al.1.0-Lilik4.)-(ci8 A",-4.4A -6c., a PRESSURE GROUT <br />a 'Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF Wg.1-6 INSTALLA_TioN TYPE <br />MONiTO RING <br /> litbIOLLOW STEM <br /> CONTMUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE Z" 1:1 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />121 AIR HAMMER/DRIVEN CASING THICKNESS 0TYPE OF CASING: fl STEEL .IKVO U OTHER: 0 EXTRACTION • / <br />U MUD ROTARY DEPTH OF GROUT SEAL I ' TREMIE TYPE TO BE USED: VAUGERS D HOSE 0 VAPOR <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: %Yes LI No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 11 AIR SPARGE/ OZONE <br />0 HAND AUGER GROUT SPECIFICATIONS -1--1,--371- 0-e-Yyi eet-+ U SOIL BORING <br />0 OTHER APPROX. BORING DEPTH 26 /50 1/ 75 ' +BOLTED TRAFFIC BOX or I] STOVE PIPE U OTHER: <br />CONDIJCTOR CASING PROPOSED (if YES. list specifications in comment section) <br />COMMENTS;(01 14. —6P) * (Cse vir 4 0. 411, • • <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 Sari Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x ,c,-2---7-2,...:L._ Title/Company 4* *F 6 e 2 0 , - AL -A g, <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # _Flown./ sgpvtr-F INVOICE REC'D my DATE <br />5.5.?1,,..... 36g. ' ez--94t ok, chmAZ- i s R# A <br /> <br />E./ 2- ) <br />C-57 \/ WC -WAIVER C-57 Letter of Authorization to sign permit V Encro d <br />ER--0 5 - <br />EFID 29-02-001 <br />6/22/04