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SITE MAP IN UNIT IV FILE2DZ3,11.7SS: <br />WORK PLAN DATED: a/ <br />, WELL PERMIT APPLICATION FORM <br />REQEIVED <br /> <br /> SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />JUN 12 2.007 304 E. Weber, Third Floor, Stockton CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 AA9e0 W.3 <br />ORIGINAL PERMIT/SERVICES 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 />Zip 9:5205 <br />Apsasrceesis#ors pti 2 (03 <br />WELL Location 2473 F, Nit S+. Cross Street Pi Ihfc4 54. City DM <br />PROPElily , S(o14 c15z.05 <br />Owner VI lIff 1 wAD ILL.J Address Z101 13..F,m4 54-, -km City 510AZip7 Phone# Yb5 • 5-51g <br />C-57 Contractor Woudisicaill Ptills14, Address 550 gitel g•ei City Pit) tit 5/git ZipP171 Lic# 7kqPhone#)37943C6 <br />Consultant/Sub CntrSindv-5 E11411 inhuitid ;4-Add rIs3s3° CvneroA Palk Dr.,4t55(C)ity 4101461/1 ALIC4 " 950 Phone# 53o 76- 04 7 <br />GIS Coordinates: X <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />VIEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />DIAMETER <br />itWELL # 11/1w-15,mtv-25) filim-35) ft1ai-q51 mw- ID <br />El *Other <br />SPECIFICATIONS <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />it Inik. ,1 I <br /> <br />MONITORING )(HOLLOW STEM DIA. OF BOREHOLE u mULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA:oi <br />oi <br />0 EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS______ _ TYPE OF CASING: 0 STEEL )(PVC 0 OTHER: <br />re <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL J 151 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: [] Yes 1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ne4Thert14 <br />OTHER: 'BOLTED TRAFFIC BOX or 0 STOVE PIPE 1] APPROX. BORING DEPTF1105 - q0' 0 OTHER <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Ord' ances ules and Regulations, and all applicable California State Laws. <br />Date <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By ..- <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQU INVOICE <br />/I\AV4 /3/9Y 0)( 6.-aq _ „SRit 400509 122—,,/' __... /. <br />C-57 WC 17 -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc /V <br /> <br />EHD 29-02-001 <br />6/22/04 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />0 DESTRUCTION (choose type below) <br />fl OVER-BORE. <br />0 PRESSURE GROUT <br />GROUT <br />Signed x Oft <br />Print Name 5W1 13; <br />DEPARTMENT DEPARTMENT USE ONLY <br />(71.g7g C. A..e.44(4 1- <br />29 „zoo -7- <br />Title/Company P 1 44 7c177 j 5 l'iii45givi'4=o pkte-w41., .7;c1 <br />/--0 <br />.35:24 <br />Date Issued 0 A <br />Date Final Inspection By <br />Date