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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /2 '/ <br />ea Date Issued <br />Final Inspection By <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspectio <br />COMMENTS / CONDITIONS <br />DEPARTMENT USE ONLY <br />San Joaquin County <br />SITE <br />600 E. Main Street, Stockton, CA 95202-3029 <br />MITIGATION <br /> <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgAtil 0 2 2003 UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE <br />isE HEA <br /> <br />Well Permit Application sNVIRONMENT <br />ifiERMIT/SERVICES <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 />WELL Location 7C, 7 ?etc ,-(c vlekk Cross Street veort, City ZipC1,6,2.0 Parcel# 0/7--'1e c), <br />Assessors <br />PROPERTY ( <br />Owner Thect:41 (c• Address 1-7>i II; IMAfrisc.( Ve*i^yZip lctic Phone# 42121 3 5 cre.t #- 32.5 <br />C-57 ContractortoAer;\ Address it:: It E.. te.,-.4ctie, Ark City AY14,6e1AN Zipq2,42C5 Lic#P195-0 Phone# )1'03966SO <br />136, <br />Consultant / Sub Cntr 6a:14-Vicki t I Irrk Address5-lif 2., 64S‘iiet-Vc t6 71:X> CityPueito,) Lic:#“2- Phone# pry 8f65.4- 27- <br />GIS Coordinates: X 3Koi` 01. "3 -7 , (Ai , Township <br />Vit. till -124 • <br />WORK TO BE PERFORMED: <br />"ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") DESTRUCTION (choose type below) <br />ilsoiL BORING # o <br />-311WELL # ;2_ <br />'fl *Other <br />.N55 .6. , <br />*EXTRACTION <br />*.MONITORING <br />0 VAPOR a MUD ROTARY DEPT.440r 4GIR(3UT-S-EAL'27-' - i'2 '4 34' - 3 4EMIE TYPE TO BE USED: G AUGERS a HOSE O AIR SPARGE/ OZONE *PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 2 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />TYPE OF WELL <br />'HOLLOW STEM DIA. OF BOREHOLE,_ /OVA MULTIPLE CASINGS a MULTI-LEVEL WELL d'ZINGIIDI-A:'4 4. r'"N ..--t) <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS OW 1.4- 3 - ).-if D/A ON . <br />1:IA1R HAMMER/DRIVEN CASING THICKNESS 'icy. 'IC TYPE 9)F CASING: a STEEL )31:Arc a OTHER: <br />i ,.4._. - i (' - - ' <br />,SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Fe, 4-b ..-,, k Tr.---f- <br />a OTHER: a OTHER APPROX. BORING DEPTH sT ' 7 7/ 0 BOLTED TRAFFIC BOX or ASTOVE PIPE ) <br />CONDUCTOR CASING PROPOSED _Xi 0 (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />(3.0-4.-.7L4 ktibv ,v6 Signed xl-Thl_f-2 C Title/Company <br />Pnnt Nartie /CI (-1'61'4'3 A. Ortrtilitr-r- <br />ACCOUNTING ONLY: AID# FAC# L-) 1)/)3-;±) / <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT/ - , - • I T# INVOICE <br />a550 I t\14) V - -a ) 6,,,,,,. 1 _2_ - Di' SR# 053251 <br />C-57 t/- WC v -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit t, Encroachment doc <br />Environmental Health Departme E <br /> <br />Range <br /> <br />Section <br /> <br />COMMENTS: j Lçe rYlskt II <br />1:1 OVER-BORE DIAMETER <br />fa p PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Date /(-61 -d <br />EHD 29-02-00 I web <br />6/22/04