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I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin <br />County rdinçes, <br />Signed x <br />Print Name <br />lations and all applicable California State Lays. <br />Title/Company 507-kr L-t)Cra <br />Date L9' —z <br />A i/Aktck. <br />46,06eNeo,tvo-4-L <br />SITE MAP IN UNIT IV FILE, ADDRESS: co <br />DEPARTMENT USE ONLY <br />/Z-oct-7 <br />WORK PLAN DATED: 64- 311 2.c702 3 1 ZOO 2 <br />WELL ERNI" APPLICATION F( 1M <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 SAN JUAULAN CUSJTY <br />PUBLIC HEALTH SERVICES <br />RivIRrThripm; FirAI TH DIVnOtd 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 21(rel rzlSri, Cross Street 64Z4014146 City 1-r--4_ei, Zipg..37() I sarsceeZrZ? 020 - K2- <br />PROPERTY Owner Li& rel-Srt Si.Address 2 t 0 "Z-3Sr 12D City 7r0t/ Zip q:3-'76 Phone/2))Y -407 <br />C-57 Contractor I 1-640.-wi.iakidressie4 maAzzo t'Z4y cay=2,et Z.10.-Po Licaria4(7 Phone00).-311.,? <br />Consultant Sub Cntr A-T41-6-a-X1,40-fhlrAddress ((9.. 7 S f 404-12 City Skia .11-77Li 227 PhonekrZak ?)7"Zrefelfo <br />GIS Coordinates: X , Y , Township Range Section <br /> <br />VA <br />1RK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />I] SOIL BORING # <br />*WELL # itetki-10, /Lea - 7 <br />Grout Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 11 MULTIPLE CASINGS? El MULTI-LEVEL? a WELL CASING DIA: <br />CASING THICKNESS 50 to TYPE OF CASING: 0 STEEL 43-PVC 0 OTHER: <br />DEPTH OF GROUT SEAL -*pais TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br />GROUT SEAL PUMPED: )i- Ys a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') . <br />GROUT SPECIFICATION'S: 6P-72.41-0> ref- ' <br />..1_, <br />Ja" <br />APPROX. BORING DEPTH /1.4(01tf ,OOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? k .1 Di ( if YES, list specifications here): <br />Fe_ AlLim/e, km- c.i.i.--,4/ i.tz,ci--? — a al acco' , , I <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDMONS: <br />Date So <br />Date <br />50( 0.7 <br />Date Issued 2-41e)Are <br />Final Inspection By Date 6 I <br /> <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM • -' CE REQ INVOICE <br />'S S-0 1 IP. 43 7 — .?ze ie-e Zj /k16-i- 51. 1905 ci s-- 7- <br />, N. <br />PAYMENT <br />RECEIVED <br />JUN 2, 6 no? <br />SITE <br />MITIGATION <br />UNIT IV <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />fl PRESSURE GROUT <br />*Other: <br />COMMENTS <br />TYPE OF WELL <br />teMONITORING <br />0 EXTRACTION <br />El VAPOR <br />*COMMENTS: Pe-126, 417- <br />(I AIR SPARGE / Ozone Q PUSH POINT <br />El SOIL BORING 1:1 HAND AUGER <br />0 OTHER: fl OTHER <br />INSTALLATION TYPE <br />HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />tAA-c-ei <br />C-57 <br /> <br />WC -WAIVER C-57 Letter of Authorization to sign pe'rmit <br /> <br />8/29/02 <br />