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KtLu,c}e_ Print Name <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 Ordi ances, Rules and Regulations, and all applicable California State Laws. <br />Signed x cut.a <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: -LT; çS Arvt VvA WcA-1 <br />WORK PLAN DATED: &4....v ,s‘c 1-4k cL <br />Title/Company CvectOrtAt Cru <br />Date of Ii <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING OLLOVV STEM <br />EXTRACTION fl AIR HAMMER/DRIVEN <br />VAPOR UMUDROTARY <br />AIR SPARGE/ OZONE <br />SOIL BORING <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />(7,(1 DIA. OF BOREHOLE U MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: _ <br />CASING THICKNESS 56.A. 4 TYPE OF CASING: U STEEL l(PVC OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE U ED: ,'AUGERS U HOSE <br />B PUSH POINT (GP or CPT) GROUT SEAL PUMPED: U Yes %No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS lAR.,,c)A-- m,1 <br />OTHER APPROX. BORING DEPTH (C21:72- BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED ktO (if YES, list specifications in comment section) <br />-- <br />Area <br />Date Date it -L1 j,o1 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />„„Ak cLc*AA-- <br />Date <br />Date <br />Date Issued <br />Final Inspection By <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIROVEN [ HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PEKiliT/SERVICES (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />JAN 2 "?.007 <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 />WELL Location 2 7-- <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />---5r) Cross Street — (51-rea City .k15C.CIA„ Zip acp Parcel# 1011 "'C.& -139 <br />2..pr .44 Assessor n <br />1 -ec 3 2_ City %a-AN Zi <br /> Phone#43 9)i1-11-0144 PROPERTY Owner tV4,1,-L--1)-CA" 7 Address 0 w t <br />57 <br />C-57 Contractor MI (.,ketkAPC0,-LicttlANAAPACitdre ss ?lectsciAd- ity ViCe.t..e.6111:41P CW7Lic# S4/ 35:IP hone# !c -'3 .g- [39 <br />Consultant / Sub Cntik <br />9 <br />yoNkem,i(41 Address 1446) *5- cit 0. D ic# Phone61 2-0 GxviNi <br />GIS coordinates x <br /> <br />, Y Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />AIEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />fl OIL BORING # <br />WELL # <br />a *Other <br />COMMENTS: 5 e etA <br />fl DESTRUCTION (choose type below) <br />OVER-BORE DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE - 0 EST # INVOICE , <br />SIRtt Quzkovo1/4(..• <br />C-57 ‘7. WC 1/'-WAIVER 9/30/02 C-57 Letter of Authorization to sign per ncroachment ---