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TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI9ATIONS <br />O MONITORING a HOLLOW STEM DIA. OF BOREHOLIvil‘ka MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /V-A- TYPE OF CASING: a STEEL a PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3f, r-42/4-----FREMIE TYPE TO BE USED: A,ACJGERS G HOSE <br />0 AIR SPARGE/ OZONE ,(PUSH POINT Or CPT)GROUT SEAL PUMPED: a Yes a rie(I'lpTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />);140IL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: 0 OTHER <br />I CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 5-b,,y/4-19 <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 Ordinanc s, Rules an - -gulations, and all applicable California State Laws. <br />Signed x <br />Print Name kV, IL;iev-r f/17-1 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />COMMENTS / CONDITIONS: <br />Title/Company 6- /77 <br />Application Accepted By Li/71 <br />Grout Inspection By "Irt - <br />Destruction Inspection By <br /> <br />Date Issued <br />Date( '1(7 Final Inspection By <br />Date <br />tus/ <br />Date 9 <br />Are /e <br />San Joaquin County <br />Environmental Health Department <br />REsc <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdS EP <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 oaquin County Environmental Health Department. <br />WELL Location 110 (A)- Sad t a j i L Cross Street City ce Zip Parcel# / <br />62_,,,T , Assessors <br />0 <br />9176 4..., Address i25 Al'‘' Pothcit,%62Pcdzi PORT R6 <br />p9:52,62-Phone# <br />C-57 Contractor 74-& Address / G-- 7 cAiwAiiicitOzaligii 4,-47-is-t'sv4gZ# 4, 7/O-6(0 <br />t,f_siTE <br />JMITIGATION - 7 2UUb UNIT IV <br />Well Permit Application ENVIRONMENT 4-4.4E+4-1 <br />PERMIT/SERVICES <br />Consultant / Sub Cntr Address City <br /> <br />Lic# Phone# <br /> <br />GIS Coordinates: X <br /> <br /> , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOF., HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BOP NT-Z.7-C <br />a WELL # <br />a *Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />1:1 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />ACCOUNTING ONLY: AID# FAC# S --K L9f) IR I I <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM! -' - EQUEST # INVOICE <br />3563 /9 .2_8.5 4 3-) (4 -2rezil‘,;; sR# LI <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04