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WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />0 SOIL BORING # <br />0 WELL # <br />*Other <br />COMMENTS: "Th e vim ( acii u); )) <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) )(DESTRUCTION (choose type below) <br />LOVER-BORE. DIAMETER 9A" (.?'.h.5: crks) <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS icitrd_lavtd <br />er6.cs ure- cnv+.a. <br />that I have prepared this application and that the work will be done in accordance with San Joaquin <br />ances, Rules and Regulations, and all applicable California State Laws <br />I hereby certi <br />County Ordi <br />Title/Company ereP1/407if&k <br />Date 3// //OLE <br />Signed x <br />Print Name iAtt 13*thire115 <br />n Joaquin County <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />Envirmental Health Department iu-SITE <br />MIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdmAR 1 72006 UNIT IV <br />Well Permit Application <br />ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Locations 230 Al- Wee /ant Cross streetairrie 4 vt City 34ciarpt• Zip q5207 Parcel# //1 -0?0 <br />opRwonep rezycLobtn johae <br /> Address5955 htliStarj (11 City SiDCH7/71 Zip?52 /0 Phone# 2-0 i -? (1 2 - 7(2311 <br />Rartcp. C-57 ContractorereCadibr; III Address Vg2 Vine, et?Cle City evIMVa- Zip 95'.7f2 Lic# 4/15/ 0 Phone# 9//i - 6 gr - I )1g? <br />Consultant/Sub CntrAtilniffed 6eDEnlitreelitoaddress g31Shat() RC1 CityMI7C-Ory, Lic#(6g0227 Phone# 2oei -4(o7 - j DOC:7 <br />GIS Coordinates: X Y Township 2-44 Range 42E Section <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[1 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 1:1 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3Z3 0 14 0 (-1-1-1 W est La n e. <br />WORK PLAN DATED: M re,I.L. 13 2006, <br />Application Accepted By Vit,to rc6 L, M ce_42, r - 1- rieti Date Issued 3/ Z ill GI /. <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By y+e-rl' L. ni Date 3- 30 - OZ. <br />COMMENTS / CONDITIONS: De $ -he t/ E- 4-j 0 rl 45-P 111 0 r) ,-o r ). rLA NiNi e l) t M 14/ - <br />Area 1451 <br /> <br />ACCOUNTING ONLY: AID# <br />.., <br />F <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE:I,. - v - —"fiat. - - INVOICE <br />._) <br />35" 0 2, <br />35 0 3 <br />4 60 #` do 277 <br />74 SR# 00 4_6 i ,?, 7 <br />C-57 Letter of Authorization to sign permit ent doc C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04