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PROPEr''' <br />Owner <br />C-57 Contractor <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />)liNIONITORING 0 HOLLOW STEM <br /> <br />EXTRACTION fl AIR HAMMER/DRIVEN <br /> <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE/ OZONEAPUSH POINT (GP o <br /> <br />0 SOIL BORING 0 HAND AUGER <br /> <br />OTHER: °OTHER <br />GROUT SPECIFICATIONS 5=779 /1y-e-e O,4 '//6 <br />APPROX. BORING DEPTH /051 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 4.4e A 7-7.4e/017 /1141 (/.0,4/1 ic` AA/e/eAk-n't 4ozo-ecr-s4' 710 <br />zi r /1/,- G#4e/..-0/z.-4./A <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 21/ U MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL g PVC fl OTHER: <br />DEPTH OF GROUT SEAL FLA:CPC/77W TREMIE TYPE TO BE USED:AA_UGERS 0 HOSE <br />)GROUT SEAL PUMPED: a Yes 'No (NOTE: MAXIMUM FREE- A L DEPTH IS 30) 0,-“,v)V) Date <br />Date <br />Final Inspection By <br />DEPARTMENT USE ONLY <br />,23i /v- a0,/.7c - Le/4) 2) <br />00/6 6 <br />SITE MAP IN UNIT IV FILE, ADD <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br />COMMENTS I CONDITIONS: <br />Cp-r 04 05 ei,e3->vg,e. <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 />,Assessors e <br />WELL Location /3/5" /1104/iial/f//4 Cross Street //1/1/6 City 5101---1-41,11 Zip ?..C.40#Parcel# OS - ROW <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br /> Address o N Autdis 57e4A7eA/ zoK Phone# 7-ag 93 7- • gip <br />Z4 ,a0/.(-1/4/4". Address 45iR1Zc,%2 CityliiiteaViYeaip 70-53Lic#‘CO7Phone# 90g....?/3 00Z) <br />Consultant/Sub Cntr bi-/4. Address SW2 fkry /et.* ity4,Z6Lic#e 5 7707 Phone# 7295/141 <br /> <br />, Y , Township Range Section <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING (CPT GEQPROBE, HYDROPUNCH, HAND-AUGER, OTHER') LJESTRUCTION (choose type below) <br />SOIL BORING # cPr-4e 3 d- ..; • I] OVER-BORE. DIAMETER <br />0LL # - - _ --- s 'PRESSURE GROUT r <br />0 *Other 'GROUT SPECIFICATIONS ,... <br />COMMENTS: <br />GIS Coordinates: X <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 Title/Company //z/e if,/47/616.5€ <br />Print Nameoefle/AC: V:44Stel Date <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY 1 DATE - 7---"-,...,...,T# INVOICE <br />350 , 5D IA sR# <br />EHD 29-02-001 <br />6/22/04 <br />-WAIVER C-57 Letter of Authorization to sign permit V Encroachment doc,/ <br />7612f/