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12(A) 40 T.0 1.1a p re-s5 <br />ssure_.? zaw-"sit• • <br />C-57 WC -WAIVER <br />EHD 29-02-001web L,L) en e5-+r <br />6/22/04 jev\g„...‘ .44,4 r k).6 <br />Cal. 60 <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />re-.5 are- n-ro l•NA L) e_a_vv Ica) <br />\Jib, 3' a.c.4_ e, I I cAstyk5 <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 Fr-,) <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />Ay <br />?O7 <br /> <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 />1115.3 and cf.,nd.rric cif San Joaquin County Environmental Joaquin County Develppment_Title, Chapter 9- Health Department. <br />WELL Locaticx I 1 _ (00 ' , - 3 0 r\O reA-- Cross Street • 411 Al 1 %., <br />Owner <br />PROPER11_, 51-&-464 Address 12-5 /444k <br /> <br />Alf ' 3-1&-/-11.11ip /5-:202Phone# <br />C-57 ContractoA5C4k Doll: ddress 2- °Thee 7' cityr-41,C 0 Zip/5-7/2Eic# 717514honeeko 16---SV He? <br />Address637 shao lei- Citys-h440 Lic# Phone# 4,7 IDDlo Consultant/Sub CntrAAE- <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # <br />[I *Other <br />COMMENTS: 01/111 bec(nkdiejA <br />,reESTRUCTION (choose ty,Re belov,) <br />kt5VER-BORE. DIAMETER 661 <br />'411;RESSURE GROUT <br />GROUT SPECIFICATIONS <br />0 <br />\S\ C3 a• <br />Cityce-111441 ZipeP A <br />psasmeesiltors 37 , 3 6 _ 25 _ <br />1rce)1-5 TD5.51 , <br />IA <br /> tol 4J- 4^ • <br />TYPE OF WELL <br />pIf1ONITORING <br />yEXTRACTION <br />gr'VAPOR <br />"f AIR SPARGE/ OZONE <br />0 SOIL BORING <br />_ <br />INSTALLATION TYPE CONSTRUCTION SPECIFIChTIONS <br />OLLOW STEM DIA. OF BOREHOLE 1?""111 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS /44c TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL le Rtria- TREMIE TYPE TO BE USED: ZAUGERS 0 HOSE <br />a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: jr'es a No, (NO E: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS 72.141 <br />a OTHER: fl OTHER APPROX. B.42 NG DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br />VA, VIA ft 4 1)erk4i,"4"e4-)/0 "CA4441/ VW iqgatg T A <br />R (if YES, It specifi cations in comment section) <br />COMMENTS:Vq4 v Gul TD3o / 1.1-4 <br />VO 3 TD Sol toll krukeete_ piwzatate tkr, VW TOLifi io 't brukret. p.A.644.4.A.k VW,'" IV 4 101 t"4.-J4 pillage% <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 Ordin nces, Rules and Re • • tions, and all applicable California State Laws. <br />Signed x •frire , Title/Company /J1-- 1/ <br />Print Name hi R <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /10 SOrtorok ,54o <br />WORK PLAN .BA-T-C-13•: <br />Application Accepted By <br /> <br />Date Issued '6." / 1) -7 Area I 41( <br />Final Inspection By L73/ • Date .57/VA <br /> <br />Date S\Ckla <br /> <br />Grout Inspection By <br /> <br />Destruction Inspection By Date <br /> <br />33.4)6 f t-oder:kit COMMENTS /CONDITIONS: 1 1451 aj #t53 1 7 1( ban - P fr-S3kre <br /> <br />ACCOUNTING ONLY: AID# FAC# cc =--0e21)--P1/99 T <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE - INVOICE <br />3 5sci- <br />3 5"0 3 <br />Lou s <br />'t 5 <br />34 5 <br />1/-2-5610 Mt sig107 SR# 5 0(-1/5--- <br />foe.....244A4 V Loa GI. 4-11 4rD agouti-AR <br />Date 57 <br /> <br />7-