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TYPE OF WELL INSTALLATION TYPE <br />El MONITORING ['HOLLOW STEM <br />EX'TRACTION a AIR HAMMER/DRIVEN <br />VAPOR II MUD ROTARY <br />I:1 AIR SPARGE *PUSH POINT <br />)(SOIL BORING a HAND AUGER <br />II OTHER: OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES fl NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: STEEL PVC U OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I] AUGERS HOSE <br />GROUT SEAL PUMPED: ['Yes I] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH CI BOLTED TRAFFIC BOX or a STOVE PIPE <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, ri 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 />C D5 /oil-- <br /> <br />WELL PERMIT APPLICATION FORM <br /> <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 />Assessors <br />City (.5-710c ai Zip Parcel# Cross Street Co P.1442err e <br /> City 5710 el64),-, Zip Phone# <br />C-57 Contractor/4/0046)c, d.e:/4'...00 Address (-;.(>-• City #° 1/5 /-ArZip 77S 2( Lic# r7/(1 gone# V7 32 V30 0 <br />Consultant / Sub Cntr/,//e,fitovn Gq, ii7,,etWdresseti§ dRIF017a--- Ci ty14./c/ oga? /Lic# Phone# 530 <br />GIS Coordinates: X , Y , Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (CPT0PROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />irSOIL BORING # 3 --L-/ <br />a WELL # <br />0*Other: <br />COMMENTS: <br />O DESTRUCTION (choose type below) <br />1:1 OVER-BORE - DIAMETER <br />a PRESSURE GROUT <br />Grout Specifications: <br /> <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: 6 .ecvs-ol-ee. eS/ lote- T3-y -to be c/42.5)1,-c.,7-ec( <br />,..a.c( 1,6o it 0 ,1-- 40 LA_ ‘) / 6yS <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <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 San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br />\\ION° SITE MAP IN UNIT IV FILE, ADDRESS: . j.2 / / ( -6 CAltrY ‘DO \\i'e-0 <br />y--c` WORK PLAN DATED: /.4 iS /6_5 7 SO <br />Ara 0'1 — <br />,3 <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />' <br />l ril 67 I 1/67 <br />, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />350) <br />.3(: 6,17/ 2,‘ 3 /1-7 (O C' SiRit `q, )t4 . <br />WELL Location <br />PROPERTY Owner, ggest 0 #4 ,51vc-L7f..24, Address <br />Title/Company 6e 0 /ors—// 7, :iiittf <br />-7 ---A ,Ae//:-// Date 37/7/0 C, <br />DEPARTMENT USE ONLY <br />Application Accepted By M <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br />Final Inspection By Date <br />0`0 EYN"-C <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />4C044,e(p sjI JbJo <br />EIID 29-02-001 <br />WELL PERMIT SITE <br />8/27/2003