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Tilie/Company e:2165*-7 E-) 61-57 <br />Date 5/7/43 <br />Signed x <br />Print Name Ega tEi P4-1_ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: c7171-1// aatiork--- ‘14A7' fr) <br />d/ <br />WORK PLAN DATED: 1/- 44 a 2— <br />! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />Ordinance ules gulatio , and all applicable California State Laws. <br />FAC# ACCOUNTING ONLY: AID# <br />C-57 WC -WAIVER <br />Destucton Inspector, By Date <br />C-57 Letter of Authorization to si n permit....L.. Encroachment doc M <br />if <br />4 FILE COPY SITE MITIGATION UNIT IV <br />umwiNfat WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />AlIA)/4' 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 />4,plication 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 Joaquin <br />county Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />NELL Location 22 I tqi Lcc:1i__311, Cross Street0P-W111), City 5(0'2.4-00 Zpq6—Z65— Parcel* <br />3 ROPERTY OwneO-* )1, 1E1.4._ IA DT/32 Ter_Mdress C-74-tti City Zip Phone# <br />:3-57 Contractor Address 236G-ThAivtAZA M City P7,163Lic#6722-6Phone# <br />:Consultant / Sub Cntr V/2,71-11 LL Eminuaa01815",s /7_7q..g PribrAi caK LAW-Lop i Lic#015152- Phone# 207 6e-c?,3q / <br />GIS Coordinates: X , Y , Township Range Section <br />I‘ORK TO BE PERFORMED: <br />NEW WELL / BORING <br />801L BORING # 11 QPT, <br /> GE* "ROAVYDROPUNCH, HAND-AUGER, OTHER') <br /> <br />VVELL # d_D 0 3 uyeefi,„ • <br />11,2 <br />L <br />a *Oth <br />COMMENTS: 7 <br />ct:51-woo, <br />CONSTRUCTION SPECIFIWONS <br />DIA. OF BOREHOLE eKt if orr ,LTIPLE CASINGS fi MULTI-LEVEL W5,,LL CASING DIA: <br />CASING THICKNESS a .1?-0 TYPE OF CASING: g STEELteVC U OTHER: <br />DEPTH OF GROUT SEAL'i-0 4 S TREMIE TYPE TO BE USED: 13 AUGERS fi-Ht:C6E <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: g Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a HAND AUGER GROUT SPECIFICATIONS C CL-(047 / <br />I] OTHER APPROX. BORING DEPTH /57) r OLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED kJ/- (if YES, list specifications in comment section) <br />COMMENTS: N 14/1.-1) IS 1\i/ Ot ak f fl it V.... t 2Kil -116- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />PE CODES FEE INFO AMOUNT REMRTED CHECK # RE.C'D BY DATf PERMIT / SERVICE REQUEST 8 INVOICE <br />550 i Wiki °11 37(14" (ni 5-#.0 SR# g223 gOO , <br />CA/ <br />(067,-) <br />g DESTRUCTION (choose type below) <br />fi OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />SPECIFICATIONS <br />/rai /A)C, 160 <br />TYPE OF WELL <br />1ONITORING <br />O EXTRACTION <br />a VAPOR <br />I] AIR SPARGE/ OZONE <br />O SOIL BORING <br />U OTHER: <br />INSJALLATION TYPE <br />'HOLLOW STEM <br />fi AIR HAMMER/DRIVEN <br />D MUD ROTARY <br />Obeli <br /> <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection COJI1.ETED Date <br />COMMENTS / CONDITIONS: 1