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I21§1,ALLATIPILME, <br />1$1 HOLLOW sTem <br />0 AIR HAMMER/DRIVEN <br />MUD ROTARy <br />PUSH POINT (GP OR CPI')__ <br />C RAND AuCER <br />CONSUIATION SPECIFICaTIONS <br />DIA OF BOREHOLE 2 0 MULTIR1E CASINGS 0 MUL ri-LEMEL WELL CASING DIk 4 'Li <br />CASING ThiCKNESS St 4. YO TYPE OF CASING' C STEEL cfrPvC 0 OTHER <br />DEPTH OF GROUT srAL Tiii!miE TYPE TO SI VSEDPK-AUCIERG HOSE <br />GROUT seAL PUMPED GI Yes tIZNe (NOTE: MAXIMUM FREE-FALL OEPTH IS BO') <br />GROUT SPECIFICATIONS 110r4ianei .4rt9Ght <br />z, <br />DgSTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONI Y: <br />PE CODES FEE INFO <br />5-0 <br />C.57 WC <br />DATE _ <br />FAC # <br /> <br />AMT REMITTED CHECK ts RECV'D BY DATE <br /> <br />-tt fel -0° 03 7 <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />TAID ,ii1 R(J(35-4-1-'5c; <br />SR# S-19 <br />— •rn -VICE # <br />ENCROACHMENT DOC <br />SITE MAP IN UNIT IV FILE, ADDRESS (Lc. ik.ri <br />WORK PLAN DATED: 2- <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY 0,..;:s4.21_0,,j, 14-1 trc4 FINAL INSPECTION BY <br />DATE ISSUED / 3 ___ AREA <br />orvrE S:kipjf <br />RECENL5n <br />SAN JOAQUIN COUNTY JUN <br />ENVIRONMENTAL HEALTH DEPARTMEN 0 2 2008 SITE <br />600 East Mein Street, Stockton, GA 952o2-3cpwiRooR T HEAM_TIGATION <br />Telephone: (209) 468-3449 Fax; (209) 468-3433 Web: wvvw siRO0 NA UNIT IV 77 1v - RVICFS ' <br />WELL PERMIT APPLICATION <br />NQN-rIEN.N.2a$LE PEsoig EXPRULY_AR FROMILLLE, 'SUED <br />Is hereby made to San Joaquin County for a permil IQ construct and/or install the work described This application is rnade in compliance with San Applicotton <br />, Assessor's <br />Well Location ;:ka-1 0 0 •A)pisi-c-c g.fiCross Street sji-iW4.2.,12 5- ___,_ City 1-„rat y Zip / qn) , are. 4 ill:I....cc c 6c) <br />Ownerres01111 gitimery;n......k 1 . Address itoilt! c.,ke_ City at I' coin . Zip e06.9.6_ Phone # <br />nWrMer3n.r 4 LJ- • ;',r, <br />C-57 Contractor Pf.44 Dr, iii Address qS0 14We_ P-ti i City, ‘ifar4-.1•14. a ZIp PtS.S.3 Llc # 6/3,S16,..c. Phone <br />Co ocs$(0,50- Rcv Phone .5/0 • (fie T 3 5 71 (Znsuitan ub Cntr 4.44464,__ _ Address p . Ik/iia- ?:•,_,5ft.. A_ City ...C.retiazi-ile-. t-ic* <br />Range <br />GIS Coordinates: X ._ Y Township Section - <br />p2=11'ERFORPAED: <br />BORING (CPT, GEOPROBE. HYDROPuNCH. HAND.AUGLI . H '' <br />,..:.,-... <br />ID SOIL eoniNc4 .. ...__ <br />KwELL to jiikl ,,c• mw ..0 <br />Q 'OTHER Ift / /rEvt).....7....S1edla_cd.3.s.ne,f <br />COMMENTS._ii.) clis rts j..1- 4<i )-{ .1 tAourhisalicar,...ckiLz, S 14keo,j-_LL=.1 .../2_p/ --51.--c t / S itvc Tftel...., <br />Joaquin County Development Tale, chapter 9-1115 3 and the Standards of San Joaquin Counry Environmental Health Depariment <br />DESTRUCTION (CHOOSE TYPE DELowt <br />El OviR•tiioRE DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WEL,I. <br />7/ MONITORING <br />C EXTRACTION <br />v.tiooR <br />Clam sr:int/at/OZONE <br />solL Dor:NG <br />()Trim D 0THEk APPRox, OOHING DEPTH tZ(BULTED TRAFFIC BOX OR 0 STOVE PIPE <br />coNtr I' vet., urrrne -d <br />COMMENTS: Cet tioSee.-5canchet. OA 11414 1 <br />, 6_1.u.4:.AN ,Neertopooeo _ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />ared pplication 3nd that the work will be done I accordance with San Joaquin County Ordinances. Rules and <br />Laws <br />Signed <br />cifT Cr. <br />DEPARTMENT USE ONLY <br />WELL PERM/T APP <br />E,40 ?5-C1 I IblO) <br />=111 <br />I hereby comfy that <br />Regulations, a <br />Print Name <br /> <br />TitifiliCOMpan y kcvna4a- <br />