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Signed x Title/Company_ Civ 614/4 /111661e— <br />DEPARTMENT USE ONLY <br />N. a-6d <br />WORK PLAN DATED: /O-?-i 5 <br />Print Name /1"01,16 VI' A C,"4 <br />r3P4 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br /> <br />Date Issued Area <br />Date Final Inspection -Date 47 <br />Date <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: 46/4° <br />ntetilL GINAL <br />NOV 92( 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 mAATION <br />ITE — _in <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ENVIRONMENT HUNK IV <br />PERMIT/SERVICFS <br />M W/ W-4b <br />San Joaquin County <br />Environmental Health Department <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 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 />73 5— N• Ciatirac/via 5-r C ross Street P //V <br />Assessors <br />WELL Location/ _ „, <br />City kr-4170 41 Zip 7:,:40/ Parcelfti_ 2'.› 3,5 — <br />4/e) <br />Owner Vet till n/44 /A/ Address 6-84.5.- fritid4/1/li rtege City 5-72e414 7V/1) Zip 750/9 Phone# 2"07 9s7 k/i/6. <br />C-57 Contractor 96er/e4/44 6)(Add Address 1365- 1144 a/4 Is4 "City .claie4,G1 Zip95-10S-Lic# 5/2266Phone# Alf 41625 27/Z cConsultant Sub Cntr 61'44'a - Address S1442 5/,,,t,y4o4,eityieliv7.54W Lic#6 57 207 Phone# 5'/6 -7Z9 .57,49 <br />GIS Coordinates: X , Y Township Range Section <br />PROPE <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # <br />a WELL # <br />O *Other <br />COMMENTS: <br />/DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER g" <br />'0 PRESSURE GROUT <br />GROUT SPECIFICATIONS 5.7"d/e,•ai~ <br />/65-4,L-ks <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S 'I a MULTIPLE CASINGS 0 MULTI-LEVEJ. WELL CASING DIA: <br />CASING THICKNESS .&Z.1--1 LtO TYPE OF CASING: a STEEL XPVC fl OTHER: <br />DEPTH OF GROUT SEALFCAA- Ct-P7W TREMIE TYPE TO BE (SED: UGERS a HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: <br />' <br />g No (NOTE: MAXIMUM FREE- ALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATION -C-70, 4.st-t/ fl , 0 ,eie 4ir 4 .5646/z Ce1"161v7. <br />a OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or D STOVE PIPE <br />i CONDUCTOR CASIN PROPOSED (if YES, list specifications in comment section) <br />2 x 90 (0,e/4 //vA e.) tit.L ev-r s?- n 0x '76,' 4N.D 4 071.trr", <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 Ordinance, Rujes and Regulations, and all applicable California State Laws. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE P SERVICE RE <br />.502- 11-Iq <br />SR# 0 00013 <br />C-57 WC ft-WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit V Encroachment cloW <br />TYPE OF WELL <br />)(MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />MOTHER: IP 01 0 ( <br />INSTALLATION TYPE <br />g HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />COMMENTS: i,6010 /*1,-/