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J MIT! N <br />uNIT IV <br />EIVIRWAST <br />PERMIT/SERVICES <br />PROPERTY <br />Owner PAvt S ;A k_ <br />C-57 Contractor Gr c)5 rlill /10) <br />Consultant / Sub Cntr <br />Address M /City K ziplgtr.e S phone#ci.cP ) V tu Z.- :52.7 <br />Address Cl5 Hr w1 AD , city /44fT1 r ZipTIS Lic#(05 Va7 Phone$66) c` <br />Address '7 5\# i9. CityS rol Vutic# ($ct2 Phonek2-0) ‘') --/ 0 k) <br />VW:1x <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <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 />OC,41 %A/Ay/ Assessors <br />WELL Location 1 0 1 s WI )$.1 V4,1 Cross Street ;NIRO 7 51-.1 City S Toc...Kip. <br />c <br />,. Zip 1 -7 4 c-1 -7 Parcel# 0 7 <br />GIS Coordinates: X Y Township <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />SOIL BORING # <br />ELL # <br />a *Other <br />COMMENTS: S wr.r K (////5/c, 5" ) <br />Range Section <br />DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />pROUT SPECIFICATIONS <br />5 Rev;5c.0 \.ç jç (ti5/2.314 <br />GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />CPr- <br />TYPE OF WELL <br /> <br />INSTALLATION TYPE <br />1:1 MONITORING <br /> U HOLLOW STEM <br />a EXTRACTION <br /> U AIR HAMMER/DRIVEN <br />a VAPOR 0 MUD ROTARY <br />U AIR SPARGE/ OZONE RUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPT-H I 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS it r T /A ,,,o 1-7V Cs- .M. <br />['OTHER: 0 OTHER APPROX. BORING DEPTH 1 (or) e 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NM" (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 />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 /0 NA. Title/Company A CS)/ k i Q /c 5'; / A.6 E - .._../ <br />Print Name i I'M i= Th y J.CvE114.. Date 0 G/2._3/ cz, 10 <br />DEPARTMENT USE ONLY <br />/0( 5, Za7fon <br />.( <br />Wai <br />A. ..572,51 <br />Date 0/-27/01r Final Inspection By y <br /> <br />1( <br />Date Issued <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM JEST # INVOICE <br />$11)f 0 <br />, , ,_ , , i 'i - f , ' ,, J o R# 00 z-i 72.. 1 8--""--•i <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perm Encroachment doc <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE I VI a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: Al/A <br />CASING THICKNESS NO TYPE OF CASING: ['STEEL a PVC 0 OTHER: AO <br />DEPTH OF GROUT SEAL 1‘ e TREMIE TYPE TO BE USED: I] AUGERS 11OSE <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ////670.0 <br />Application Accepted By /(4, <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />21/0 <br />Date <br />Date a722fr <br />Area <br />EHD 29-02-001 <br />6/22/04