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San Joaquin County <br />Envir nental 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 /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />2116 NOV 10 PM 1:05 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apQl ioj dM1 gitpplArice with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health beirtirmit NHENT AL <br />&O 1 .TU4'VIPIi21 Cross Street L;n GO/ n City SI-C1 46 Zip Parcel#4 4 01.1 fr ticw,D4 DIVORM1ENT <br />OPRwOnePrERva,bk /(617. <br /> Address /C3 6trarr--Wle-C+ City/14 0k-SiZ.) Zip(?-3C'Phone# 5D(-7- 22 <br />C-57 Contractoir. pr-i- I b vk9 Address C1,,,C7N City 4A27I-0-60)C4- 7'50Phone# q/2 633.3/0 <br />Consultant Sub Cntr 116 e AddresiA7 ei City-Cfa c# Phone# e, /b 6 <br />GIS Coordinates: X Y Township <br /> <br />Range Section <br /> <br />WELL Location <br />WORK TO BE PERFORMED: <br />NW WELL / BORING <br />fl SOIL BORING # <br />o VVELL # <br /> <br />O *Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) O DESTRUCTION (choose type below) <br />El OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Ni() 1oc-)A ec4--Lcvls <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />ONITORING /HOLLOW STEM <br /> <br />EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS SPECIFICATIONS <br />DIA. OF BOREHOLE eicall MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:c2- <br />CASING THICKNESS /VA— TYPE OF CASING: 0 STEEL jy4VC a OTHER: <br />DEPTH OF GROUT SEAL AD X-f. r)0 re4tEMIE TYPE TO BE USED: kAUGERS a HOSE <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH_Z (-)Nr-71 " 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />— CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />ty? ,>`-) /-t'g4(,/-7.67)S, <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 Or inances, Rul s a d egulations, and all applicable California State Laws. , <br />, <br />Signed x t / ad , A ler 0 Title/Company E / c --j---- <br />Print Name 14711t1-1 (ii-t- Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br /> <br />DEPARTMENT USE ONLY <br />lop 1 -1-7.4-rin pi ee__ <br /> <br />WORK PLAN DATED: 21 _T-tA4 Zap 4, <br /> <br />COMMENTS: <br />ai- • G <br />Application Accepted By V L AA e_ecir -fri. ari <br />Grout Inspection By Yle14 Robir4n114.2 <br />Destruction Inspection By Date <br />Date Issued 11 - 3 -0 G Area 1459 <br />Date - 2-8 -0 C Final Inspection By kReterhk_11c(14, ritted-fate /(-- 2. 8 0 4 <br />COMMENTS / CONDITIONS: Trt S trvi ef MW-4 -film u.1)i Mw -7 LSextene.44 15'-to 30 a kid M14/-8 (sc recriozess**0 GS) <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE - 1, - :-.--6.. g - : <br />--,. <br />INVOICE <br />35.01 <br />35 o 3 <br />4 89 <br />4 ass ?1'37"1- ( R# 0048867 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permi oachrent doe__ <br /> <br />EHD 29-02-001 <br />6/22/04