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'RECEIVE D)ELL PERMIT APPLICATION FORM <br /> _MGM A L <br />SAN JOAQUIN COUNTY <br />SEP 1 0 2003 ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />ENVIRONMENT HEAL T104 E. Weber, Third Floor, Stookton, CA.; 95202 <br />PERMIT/SERVICES (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 />h <br />Assessor's1113 /0 0/ <br />WELL Location /2So . V.rt 1 faX3A 0)04.>/ Cross Street Hr 1r City Sioc,K.+om Zip 9.5;2 0 2 Parcel# <br />35w/Z— PROPERTY Owner 7-Ar/64), v. Address 1311(0 1411per ii ,-441 ,city-Saii -14 Fe zip YOlo 7D Phone#S92.6" <br />, spe;goks <br />C-57 Contracto - IN5tru Address :ct5D City 40-ctiv,t --_9V553 Lic# GQ -501)-nPhone#_qL5 3/3586E) <br /> <br />_ _ _ <br />Consultant/Sub CntrA G E Address 837 12.4(i City S40c,JC-ta‘Lic# (2g0 Phone# 4/(07 ioo <br />GIS Coordinates: X 37.16/.112. -12.1.a.7.5-053 , Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />EW WELL! BORING ( CPT, GEOPROBE, A, HYDROPUNC5I-1 HAND-Ll.GEF; , OTHER') a DESTRUCTION (choose type below) <br />"SOIL BORING #C p % -._ _. ,) . , c r t ----i. 0 OVER-BORE <br />i a WELL # a PRESSURE GROUT <br />*Other: 0 V\ — • S t VC Grout Specifications: <br />COMMENTS <br />SITE <br />MITIGATION <br />UNIT IV <br />04— C_ Pr <br />AIR SPARGE / Ozone XPUSH POINT <br />XSOIL BORING a HAND AUGER <br />OTHER: Ii OTHER <br />TYPE OF WELL <br />U MONITORING <br />EXTRACTION <br />fl VAPOR <br />COMMENTS: 601 borin5S <br />anc9 coup\ (4-ar Saevies <br />INSTALLATION TYPE <br />HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 ;" MULTIPLE CASINGS? MULTI-LEVEL? I] WELL CASING DIA: <br />CASING THICKNESS Ni TYPE OF CASING: STEEL PVC OTHER: <br />DEPTH OF GROUT SEAL -r TREMIE TYPE TO BE USED: AUGERS S HOSE <br />GROUT SEAL PUMPED: pes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: TO To Sur e. Gpaje. Groo7 <br />APPROX. BORING DEPTH 12.0 / a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NA ( if YES, list specifications here): <br />+0+c• ?ec LOCct 4 Ion (I)cjrr c-Loi <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 Or , ' • -s, Rules a 7. Regulations, and all applicable California State Laws. <br />— 41 dee Adr.- <br />Signed x 111 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued <br />Grout Inspection By Date Final Inspection B' Date <br />Destruction Inspection By Date <br />COMMENTS / CONDMONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ---------- MIT / SERVICE REQ # INVOICE <br />Print Na C •kr &4.0.0.% er (11:\er <br /> Title/Company A 5e A.+ cor ALcinceS Gec.)Env iron/1e/4a ( <br />Date 9 1-0 <br />SITE MAP IN UNIT IV FILE, ADDRgSS: SO /k-). //A-Ltik- S3:374/,---- <br />WORK PLAN DATED:c7,1-p - 0-3 <br />Area06 erY <br />PH3 <br />C-57 WC V-WAIVER 8/29/02 C-57 Letter of Authorization to sign per ....._._