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SITE <br />MITIGATION <br />UNIT IV <br />SAN J 0 AQUIN 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 />DEPTH OF GROUT SEAL <br />MULTIPLE CASINGS? fl YES Q NO WELL CASING DIA: <br /> TYPE OF CASING: STEEL fl PVC OTHER: <br /> TREMIE TYPE TO BE USED: ['AUGERS U HOSE <br />D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />Date Issued 3/ 64, <br />74 • Final Inspection By <br />C-57 WC -WAIVER Encroachment doc C-57 Letter of Authorization to sign permit <br />EI ID 29-02-001 <br />8/27/2003 <br />WELL PERMIT SITE <br />WELL PERMIT APPLICATION FORM <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 />WELL Location/.2//S: /Zit/a/ ;<. Cross Street *7 e'-C& City 4.5-71c,c44; 47 Zip Parcel# <br />PROPERTY Owner/et: X7Giee.r4,04- ei/ Address /3 ? Di- ./72I-e_ Zip Phone# <br />C-57 Contractor6,(1)celLcirr-iDap4s,ddress City /VD gf‘Zip9rf <br />Consultant / Sub Cntr4.k.174'7 6a,-,547/ftst.strl. dress /sit .e: City 4.17,0,74ki4ic# <br />GUS Coordinates: X , Township Range <br />Lici7/002 Phone# 702 y Y..?co <br />phone# 51300 <br />Section <br />WORK TO BE PERFORMED: <br />[1 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br /> <br />II WELL # <br />[I*Other: <br />COMMENTS: <br />Ar)ESTRUCTION (choose type below) <br />OVER-BORE - DIAMETER <br />XPRESSURE GROUT <br />Gro t pecifications:_we <br />17t. /621(.2 /47S/ r/frz.,7 re,fee ) 11/4/_, <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING fl HOLLOW STEM <br /> <br />EXTRACTION fl AIR HAMMER/DRIVEN <br />['VAPOR U MUD ROTARY <br /> <br />AIR SPARGE ['PUSH POINT <br /> <br />['SOIL BORING I] HAND AUGER <br />['OTHER: fl OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />GROUT SPECIFICATIONS. <br />APPROX. BORING DEPTH [I BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />/Ved..., <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />GROUT SEAL PUMPED: []Yes <br />'- <br />N T OFFSIT BORIKGS 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 />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1 2-11--S <br /> Title/Company '-'9,c2/4774- 7;4Jej74' '7 <br /> Date /4,. i? 2640 <br />DEPARTMENT USE ONLY A \ <br />2P•'-eN <br />COMMENTS !CONDITIONS: Kan /ors tOd/i5 ,n siL bp, ctri t 1 td ôGei - rOuk <br />ACCOUNTING ONLY: AID# FAC# <br />.• _ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE # INVOICE <br />350 2.. <br />35o I <br />— 4.0 <br />—2.r0 336/ `1-7‘? 3/1.-W' l, SRit Lib [Li ( <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br />Print Name <br />Signed x <br />;ci -74