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L--71 Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />I hereby certify th have prepared t <br />County Ordin ce , Rules and ,R <br />s application and that the work will be done in accordance with San Joaquin <br />ns, and all applicable California State Laws. ati <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 417k <br />Date <br />Date <br />Date Issued 3(,72 /1 <br />Final Inspection By Date <br />Area S <br />fAao Ei4t?1,1 Ic4 IAJC <br />Date .1/210 <br />DEPARTMENT USE ONLY <br />50'4 tAle_ber- <br />Title/Company J WC,. 660, <br />an 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 <br />Well Permit Application <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />WELL Location 011-`e-Ar-51- We1P-12-- <br /> <br />kl/t— Cross Street ic(- ip City 3-1-k -(7)... Zip g -- <br />Apsasrceesls#ors <br />44 1 <br />1313=Vr00 1LVA d49Address3 City S4-(AL-4-(5A Zip95-315 Phone# (-2-C'1)46 8 <br />C-57 Contractor Yilt-11414,C-0-:t• lid114 0 161/4ddress /P0 tO)4 ) CityklZi0391/1> Li4+10) Phone# (-6-1g)-gi1 0'41 <br />Consultant / Sub Cntr 6,4:11ijaZ-614/th Call Address IP8 filiankteleinde City Nrilne-letY5Y\ Li c# Phone#(7--(-)9) el•-.W' '14-1 e <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW W LL / BORING (P <br />SOIL BORING # <br /> <br />HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />EOP: <br /> <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. e oie y gi <br />a ELL # <br />*Other <br />COMMENTS: .")/L_, LIV4/11;iic <br />1:1 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />4.AA < SA-friApL.E. 5 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />U AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />XOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH D BOLTED 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 />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />0 i i $ 4,24/07 S R# 00_30 // 6 <br />C-57 <br />WC -WAIVER <br />C-57 Letter of Authorization to sign permit <br />Encroachment doc <br />EHD 29-02-001 <br />6/22/04