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215ESTRUCTION (choose type below) ,p,VER-BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />WORK PLAN DATED: 7-- rIA r 7 2- 2J:in <br />((' SITE MAP IN UNIT IV FILE, ADDRESS: I .7- _.SCiv,r2/ h -P [ct <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.oy,g/pbci..) r) <br />Well Permit Application ENVii-3C,N.f‘,..iFIVI <br />HEALTH <br />tv_vi v 0 <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 />Joaquin County Development Title, Chapter 9-1115:3 and the Standards of San Joaquin County Environmental Health Department. <br />vyELL 1,:),c tig4101 N Ofttk -X'-jr-%(14)\ )4—Cross Street et14-(..51- City L Oet , 43-m Apsasrceesls4ors <br />PiRq P F! 1 .1tir. • 41-1:74 , <br />Owner 6.7 )2 11---° p Z r Addresna) ` A Ata AI t L CitySt-it- i q5 2-7- & - , Phone# <br />••L-2- Address W37 S iNek.0 tel Phone* *7 <br /> , Township <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") <br />0 SOIL BORING # <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />OONITORING ZOLLOW STEM DIA. OF BOREHOLE F otbmucripLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL (PVC a OTHER: <br />,VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .1D ree+TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />,EKR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED:›Ces a N9 NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS i tAl A rlec-- <br />0 OTHER: <br />COMMENTS: <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State aws., <br />6 Signed x 1,11/141COV4-- L h Title/Company 7eD ogi L -7 Print Name 11v7 I) t fl L Date -7 ,-,I <br />DEPARTMENT USE ONLY <br />206 / <br />SITE <br />MITIGATION <br />UNIT IV <br />Range Section <br />2 <br />1.-Arde 41, e S{rke'4141 .2,\ 3 /7-/C7s „Tr- 1,0c51./c_leio)/-y • u t Lmwttett <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR E=CH <br />ot <br />MENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />0 OTHER APPROX. BORING DEPTH XOLTED TRAFFIC BOX or 0 STOVE PIPE <br />.CONDUCTOR CASING ROPOSED (if YES, list specifications in comment section) • <br />C-57 ContractorNa VI:1N1 1 rig\ ddress-142 cgeit_ Cs-7'/2--Lid,706/0phone#4)1(„:,-?.41 lib, <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />Application Accepted By <br />ir- 710 .7 - <br />Date <br />Final Inspection By <br />/ ?- <br />(/I. A )..4 <br />Area 62,12 <br />Date Iii12-3/0 <br />Date Issued <br />Grout IFlopectiarrey te <br />Destruction Inspection By kkartAAne-r, <br />COMMENTS / CONDITIONS: Z 4- oaik c/Vv>-t, 041-c <br />ACCOUNTING ONLY: AID# F Ac# S0. ;l 62 5q - <br />--, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER VOICE <br />4 Sr 2- <br />3 $`-so 3 <br />4i Go•co <br />41 941 -0° — 7,-&04 I (A( <br />151/77,7_ SR# 5 i IS 9 <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001web <br />6/22/04