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IGINAL <br />SITE <br />ATION <br />DESTRUCTION (choose type below) <br />O OVER-BORE DIAMETER <br />['PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />9-) <br />o-) <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />2,3/5 At <br />Area <br />Date <br /> <br />Date 57-o <br />"=4.-e--.-e (0, 2-00 g <br />Date Issued <br />Date --09/—FTial Inspection By <br />Date <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd JUL 1 8 2 UNIT IV <br />Well Permit Application <br /> <br />ENINioN 008 <br />PER011,4 AI ENT H E NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • v Roc TH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is e in compliance with San <br />Joaquin County Development Title, Chapter9-1115.3and the Standards of San Joaquin County Environmental Health Department. <br />ssessors 2320 ki ‹: A A . <br />WELL Location Cross Street City 4-1-0C 14.7 ?)Zip B-2-04 Parcel# 6-24 'S <br />PROPERTY <br />Owner • -2-4,'.•1-\L-I hi I Address Z-32° ' F.; (-:'"T' City - c-r-C)t'l Zip '32:910hone# ••'=-0-1) <br />C -57 Contractor ate1artex_ 1-7L-Address Z 6 UJI GUJI•"•••- Ziift,265'Lic# (0,123V715hone#WW).50712-. <br />Consultant / Sub Cntr EN 6 C Address84:L4-LCII-try fa i2 k•-1 CityA N'T-E1-4)P ic# 77° 7 Phone# (q 1 (6)7Zci - <br />GIS Coordinates: X 3 7 .9 7-5" y • 2-41L. <br />WORK TO BE PERFORMED: <br />)NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />'fl <br />WELL # 1\1Ai t - <br />*Other <br />COMMENTS: <br />, Township Range Section <br />TYPE OF WELL <br />-*MONITORING <br />°EXTRACTION <br />VAPOR <br />INSTALLATION TYPE <br />%HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE fl MULTIPLE CASINGS ['MULTI-LEVEL WELL CASING DIA . ?- <br />CASING THICKNESS 461-4 L-40 TYPE OF CASING: USTEEL )(PVC BOTHER <br />DEPTH OF GROUT SEAL C-0 TREMIE TYPE TO BE USED: ['AUGERS *HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ,tfYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />°SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS LS -7-0109.-11-4 l'-1 Z-0 FtrZ c1L-1 l'-' 54,<:- 4 <br />BOTHER: 00THER APPROX. BORING DEPTH 8 0 -ct ABOLTED TRAFFIC BOX or 0 STOVE PIPE <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 Ordinance , Rules and Regulations, and all applicable California State Laws. <br />/ <br />Signed x Title/Company <br />/LI/ CelA Print Name Date <br />N • _.._. ..... ___ <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />', S 3 I 0 c5. 1 6 F SR# e), sw <br />/ I <br />C-57 WC Vr -WAIVER <br />[l ID 29-02-001 <br />6/22/04 <br /> <br />C-57 Letter of Authorization to sign permlt...X EnadThertt doc rye_ <br />f)4-k q <br />