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TYPE OF <br />,'MONITORING <br />El EXTRACTION <br />1] VAPOR <br />1:1 AIR SPARGE <br />OIL BORING <br />[I OTHER: <br />INSTALLATION TYPE <br />[I HOLLOW STEM <br />I] AIR HAMMER/DRIVEN <br />13 MUD ROTARY <br />(]PUSH POINT <br />I] HAND AUGER <br />n OTHER <br />*COMMENTS: \ T •-•\ e_ <br />SAN J 0 AQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3 rd Floor, Stockton, CA 95202-2708 <br />(209) 468-3449 • Fax: (209) 468-3433. Web: www.co.san-joaquin.ca.us/ehd <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />WELL PERMIT APPLICATION FORM <br /> <br />0g-A C \) c. \AC( Li.C, NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Jäaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County velopment Title Chapter an the Standards of Jpaquin County Environmental Health Department. 112--- C-01 <br />A. ", Assessors WELL Location <br /> <br />G41-,e -\ (t1 (S Cross Street Cct s-A---cc. -41-City 5f-i, cir->S Parcel# (.72- 03()O I <br />PROPERTY Owner t-- Address 1t0 I i-€ity c-; )--.....f-J-r.)--.ZpciC220-5Phone# tvi)ct 4 ""t2:4-1- <br />C-57 Contractor k.) Address "Lha #t.re.... city Zip14-511Lic# T*5 ‘71 Phone# <br />Consultant/Sub Cntr S Address 1..,12 I ,1-N • C-11: Lk ,c,CityL11(.5.-'''il 124.1C1(5( Phone# (ct 35 <br />it_cy <br />GIS Coordinates: X , Y , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />(RNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />OIL BORING # ft la OVER-BORE - DIAMETER <br />a WELL # 0 PRESSURE GROUT <br />[I*Other: Grout Specifications: <br />COMMENTS' <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with <br />Cou Ordinances, RuIeyId Regulations, and all applicable California State Laws. <br />Signed x Title/Company C--z <br />San Joaquin <br />Print Name Date <br />tAI <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? S NO WELL CASING DIA: 7- l(1- <br />CASING THICKNESc 1-/ 4-c3 TYPE OF CASING: a STEEL AF'VC El OTHER: ' <br />DEPTH OF GROUT SEAL 3, ' TREMIE TYPE TO BE USED: /KAU ERS „vlificoSE <br />GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DERtjH IS 30') <br />GROUT SPECIFICATIONS: c <br />APPROX. BORING DEPTH 1:1 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />9 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: F <br />WORK PLAN DATED: <br />Application Accepted By L-1--K44-0c—tt, <br />Grout Inspection By a ki <br />Destruction Inspection By <br /> <br />Date Issued 04/ <br />Date (//1/Final Inspection By <br />Date <br /> <br />Area gq 7 <br /> <br />Date <br /> <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />1 <br />FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT (SERVICE REQUEST # INVOICE <br />-- <br />L.' 0 L., <br />_-- <br />i'l !°I t'r-Rif 0 C LI <.-15-H <br />C-57 WC -WAIVER C-57 Letter of Authorization to si <br />El ID 29-02-001 <br />8/27/2003 <br />WELL PERMIT SITE