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)21 02/i&tc ,cp-kaL N Airs) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE y 4" MULTIPLE CASINGS? 0 MULTI-LEVEL? l] WELL CASING DIA: Z <br />CASING THICKNES5r..11 t(4) TYPE OF CASING: 0 STEEL jPVC fl OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: XAUGERS U HOSE <br />GROUT SEAL PUMPED: Y,79,..) a No (NOTE: MAXIMUM REE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: r0C-TLi44,(po "rya-- <br />APPROX. BORING DEPTH <br />CONDLCTOR CASING PROPOSED? db ( if YES, list specifications here): <br />2 .5-0 A/BOLTED TR FFIC BOX or 0 STOVE PIPE <br />INSTALLATION TYPE <br />XHOLLOW STEM <br />B AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />PUSH POINT <br />O HAND AUGER <br />0 OTHER <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 />COMMENTS / CONDITIONS. <br />(Date Issued 66- <br />C 5aHnsPecbonBy <br />ate <br />zod Area <br />Date Oc <br />ie <br />N ikONHEN .I AL HEAL1H <br />02 OCT 21 PM12: 46 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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. <br />, Assessor's_ , <br />WELL Location 4Z4 atel&I Cross Street 112i1Ø'/7' city STbLizto"/ Zip 9S24/ Parcel# )1 - .96 - 62 <br />PROPERTY Owner CI Cr t*Srociztal Eike' Address 36 Al. it Doeiib a City 5 roa474.1 Zipir262 Phone# 737 - <br />02 23/ - C-57 Contractor/VI rt-getL Ae/W/1,-Address53 Lo 144 S arr Avid City a(lc tkit p Lic# 41 7 Phone/A04 3s-63 <br />Consultant/Sub Cntr A - E - Address 37 _caw 140. Citgrdie Ktk/Lic# 6,37d 2Z 7 phone# Ye 7,-04.6 <br />GIS Coordinates: X <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />OEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />I] SOIL BORING # <br />)k-WELL # <br />*Other: Grout Specifications: <br />COMMENTS <br />0 DESTRUCTION (choose type below) c--1 <br />I] OVER-BORE -C <br />0 PRESSURE GROUT <br />TYPE OF WELL <br />fl MONITORING <br />EXTRACTION <br />fl VAPOR <br />XAIR SPARGE / <br />0 SOIL BORING <br />0 OTHER: <br />*COMMENTS: <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 9_51. inance <br />Signed x <br />Print Name <br />les d Regulations, and all applicable California State Laws. <br />Title/Company ri:41-1- akitioaa/Militkii46 <br />Date <br />- <br />Date <br />DEPARTMENT USE USE ONLY <br />ACCOUNTING ONLY: AID# <br />‘... <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE , PERMIT! SERVICE RE 6 EST # INVOICE <br />---,-, 3 5 0 \ 9 r) .00 LL i —1 Joh2ik5koo..3 (0 n 77 I 9-s CY t <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorizati‘n t i4 pfermit <br /> <br />8/29/02 <br />