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OR! <br />SITE <br />MITIGATION <br />IT IV <br />TYPE OF WELL <br />fMONITORING <br />O EXTRACTION <br />0 VAPOR <br />O AIR SPARGE/ OZONE <br />O SOIL BORING <br />fl OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />4KOLLOW STEM DIA. OF BOREHOLE 6ll MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. 2 1 <br />0 AIR HAMMER/DRIVEN CASING THICKNESSgm_ 1 criaTrE OF CASING: 0 STEEL ))4VC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL r-7 I TREMIE TYPE TO BE USED: 2lAUGERS 0 HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes p No (r1 MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS p <br />0 OTHER APPROX. BORING DEPTH evS"Fa2erl— %BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />/164) ) -ID /14,G09 <br />4 <br />Alen Joaquin County <br />EnvirMnental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: wvvw.sjgov.orgiehd <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 />WELL Location <br />, 2 / 4 x)e,t4 Cross Street Ti Hie Lewis bpcity -'114-U Zip 6154Ze sessors <br />arcel# /6 3 3 / 00 <br />PROPERTY <br />Owner Address 2 7 0 City`-.57 4:05: .Whone# 9 52— Ce-e." 12 PI f"" gebx <br />C-57 Contractort&-t4---- AddressIbte,k6.42 1141- 111 1ty A.N44/4/ e--LtiZip.(92 Lic# e/49/1 47-ione# 71`214-3.3 075V <br />ortant Sub Cntr P411-7 ( Address ---.S.7 ,-Sita..4.1) p4/ atysicciAleitic# Phone# 4716f) / D(:) <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />O SOIL BORING # <br />0 WELL # <br />O *Other <br />COMMENTS: <br />_21DESTRUCTION (choose type below) <br />411-9VER-BORE. DIAMETER <br />.E'PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <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 Ordinances, Rules and Regulations, and all applicable California State Laws. , <br />V2 —ALAA_-- Signed x - Litik <br />7 <br /> <br />C 4 Title/Compan'y e--)F -tX"---) -51+- / L(....? F _ <br />Print Name IAA )1(..0.-k-kt, (._ Pit(2_ Date Y//9 /- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 21q1 1\iavy Dr)ve. <br />WORK PLAN DATED: Apri I lei, 2oot„ <br />Application Accepted By \JIG. art • L me. Ca r+r7 e <br />Grout Inspection By ,,., „y,__41W ,./„z Date <br />Destruction Inspection By Date <br />/7 -0 t Final Inspection By <br />Date Issued ri1 28 zo0 <br />AO! <br />Area /45-9 <br />ate - - o <br />COMMENTS! CONDITIONS: De S tri.ic f, ay) o f -2 -3 -4 -s- -6 -/ -B <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SE.Ilyip REQUEST # INVOICE <br />3g 0 3 <br />35-0 2 <br />..2 in g31, 00 4. to s o 0 <br />C-57 <br /> <br />WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit En <br /> <br />EHD 29-02-001 <br />6/22/04