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a DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />--9 a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />• Cci <br />an Joaquin County <br />Envirtnimental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, Ck`95226 2006 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: wwtrONO <br />VHEALTH UNIT IV <br />Well Permit Application PERM IT/SERVicEs ORIGINAL 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 WELL Location I31 so,AT1-4 .s19-6.V1- Cross Street WASH t&./,TOM Z1. City SIDcK11) Zip qC2C Parcel# 13 17 300 12. <br />PROPERTY <br />Owner C I.TY OF nrDLX:rt! Address 1-1 2-15- kJ, F:1- Pc4f.,A00 st. City f.;:rcc.Krt) Ni Zip c152ci Phone# (.2-01) Q3"1- <br />/O. JO - 0 7 izaiAttiee -/b ).„4 ,.7.4 6 31, 3 2, 0m64- di NZ L 6 at s i rsa-ki e.orvires. 7/ 7 57 4, <br />2`14` 9 C-57 Contractor . u' AddAss "2-2Z--41.—r.. City 4' Vg:4 Pt=o444,r zip qS-742•Lic#ge 733'1 rhoneg( 7 =-, ) (1 :1 <br />Consultant/Sub Cntr EL Address /070 01„0 /71..A66T411.4.6- CA City Sk..P_Am.etkr risLic# Phone# ((II& 6'C-4 - 6 i Z"/ <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />X NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />O SOIL BORING # <br />%WELL # W-1)2 <br />O *Other <br />COMMENTS: CP <br />TYPE OF WELL <br />X MONITORING <br />a EXTRACTION <br />a VAPOR <br />a AIR SPARGE/ OZONE <br />a SOIL BORING <br />a OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 7"0 MULTIPLE CASINGS 1- MULTI-LEVEL WELL CASING DIA: • <br />CASING THICKNESS '5E: k • '10 TYPE OF CASING: OSTEEL XPVC a OTHER: <br />O MUD ROTARY DEPTH OF GROUT SEALAPPP>4 10 I TREMIE TYPE TO BE USED: 0 AUGERS YHOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: X Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />fl HAND AUGER GROUT SPECIFICATIONS Sligootr g6" 11S" " "1- 64C rut eC <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />O AIR HAMMER/DRIVEN <br />VM 1161 XOTHER APPROX. BORING DE <br />1-/ <br />PTH Its +t, )(BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section)j) <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 Ord -nances, Rules and Regulations, and all applicable California State Laws. <br />Signed x „ii- <br />/ <br />U4,\D Title/Company riki&I/jr-E)Z IA; <br />Date 12 /11 /06 e 6 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I 3 1 S . Ce-n+e-r sto n <br />WORK PLAN DATED: Oe..+ober ) 2 00 G <br />Application Accepted By Y4ora L. Mr , (IA ri-ney Date Issued if 2/ o 7 <br />Grout Inspection By alitiog....e&Liddose.2 Date — 2,9 - e 7 Final Inspection By V tardti nit& Date /1-.29 bo 7 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: Zn.rtetlf Ind - 12 :1) "2- <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT ! SERVICE REQUEST # INVOICE <br />350! 91' 8 9. oo °.89.00 (-61# 0,049 279 <br />Print Name V,Ot gAlaCt+02-- <br />Area 145 9 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ncroachment <br /> <br />El-ID 29-02-001 <br />6/22/04