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, Township GIS Coordinates: X , Y Range Section <br />fl DESTRUCTION (choose type below) <br />U OVER-BORE <br />II PRESSURE GROUT <br />.yri4 <br />ORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDRJOPUNCH, HAND-AUGER, OTHER*) <br />g SOIL BORING # _Z <br />WELL # <br />*Other: Grout Specifications: <br />COMMENTS <br />C-57 8/29/02 WC -WAIVER C-57 Letter of Authorization to sign p rmit Encroachment doc <br />PERMIT APPLICATIONOORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 />WELL Location 6- eim-tALeav X-6,0 Cross Street ,..cdra Zip Parcel# <br />Assessor's <br />PROPERTY Owner <br />C-57 Contractor <br />-5'09'114 Cr Address .S /1,30/&- Lic# 6fai 7 Phone# Consultant/Sub Cntr City <br />DEPARTMENT USE ONLY <br />Date MAI <br />Signed x <br />Print Name <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE.2" MULTIPLE CASINGS? U MULTI-LEVEL? fl WELL CASING DIA:A4 <br />CASING THICKNESS A/4 TYPE OF CASING: U STEEL a PVC fl OTHER: 4/4" <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />GROUT SEAL PUMPED: U Yes OfitNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: /3e7410.4.0(Air-4-74 <br />APPROX. BORING DEPTH 2S-1 a BOLTED TRAFFIC BOX or 1:1 STOVE PIPE <br />CONDUCTOR CASINGfROPOSED? if YES, list specifications here): <br />ACILke— 441-4- Aeos. TierAc41.-. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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' nces ujes..apd Regu ati s, and all applicable California State Laws. <br /> Title/Company <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />COMMENTS / CONDITIONS Stz4 *S-7P\ <br />TYPE OF WELL INSTALLATION TYPE <br />['MONITORING I] HOLLOW STEM <br />EXTRACTION fl AIR HAMMER/DRIVEN <br />VAPOR fl MUD ROTARY <br />O AIR SPARGE / Ozone feUSH POINT <br />f6;eSOIL BORING <br />OTHER: <br />I] HAND AUGER <br />a OTHER <br />*COMMENTS: <br />c5, Area <br />Date <br />Date <br />Date Issued f/ 7- <br />Final Inspection By Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />ACCOUNTING ONLY: <br />U) <br />AID# . <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />,?9.0/ el4;-- 'CG1 U./ 03 14-t- 1001, 5,e_oorFoo <br />City ..9-et.^— <br />,...centi 4.er-4t ‘1 Address -50 44 dits:g40 'City S/A-4,---- Zip 95?-04hone# <br /> <br />Aiv (lea env Address OfTh SAptv- Al City qfiA..- ZipY-W-C-Lic#61101;Thone# <br />SITE <br />MITIGATION <br />UNIT IV