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0 AIR SPARGE / Ozone 'PUSH POINT <br />KSOIL BORING a HAND AUGER <br />0 OTHER: U OTHER <br />TYPE OF WELL <br />U MONITORING <br />fl EXTRACTION <br />0 VAPOR <br />*COMMENTS: y Sal I bort (15s. <br />(Aft c.9 Cour% uj (..4-ttr Sae"ele <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />INSTALLATION TYPE <br />U HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />U MUD ROTARY <br />+0+0.1 boriAls etc 1,2Corliciii (1)crr C-4.03 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 MULTIPLE CASINGS? a MULTI-LEVEL? fl WELL CASING DIA: <br />CASING THICKNESS SV A TYPE OF CASING: 0 STEEL I] PVC fl OTHER: <br />DEPTH OF GROUT SEAL TD TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />GROUT SEAL PUMPED: 54,Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: TO To Sur ct..C.e. (re. Groul <br />APPROX. BORING DEPTH IZO 0 BOLTED TRAFFIC BOX or El STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NA I if YES, list specifications here): <br />4) <br />Date Issued <br />Final Inspection By <br />UkR5INAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stookton, CA., 95202 <br />(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 />Cross Street Harcilt-n 3 City Siec..K.+on, Zip 95'62 0 2 Parcel# —US RtI 14) <br />Assessor's <br />WELL Location 125o N.isOn <br />PROPERTY OwnerCI 17 of 540c-416 A-I Address 2-5 1Y. <br />• <br />, • frAJ Zip Phone# r• • ••••'' • c,, <br />C-57 Contractc 61.1:15IP.J Si-ru- Address 95 0 t+awc acityibleip315-53 _Lictia,Yoi-..'hone#325 i3 sroc), f‘7 <br />WORK TO BE PERFORMED: <br />*NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCII HAND-AUGER, 01-HEW) II DESTRUCTION (choose type below) <br />"SOIL BORING #_C— T - T- 02, OVER-BORE <br />U WELL # 0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS O(\ e-c,+ Lci„e t)c Liu its°, <br />RECENED <br />SEP 10 2003 <br />ENVIRONMENt HEALTH <br />PERMIT/SERVICES <br />SITE <br />MITIGATION <br />UNIT IV <br />oFF: <br />-&5 - <br />Address ga7 laS City 54004.1-EALic# (2 20 Phone# /00(0 Consultant/Sub CntrA GE <br />GIS Coordinates: X 37.16/0/12.,y-r2.l.a."i3cs3 , Township Range Section <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 ,1 -s, Rules a Regulations, and all applicable California State Laws. <br />Signed x /11/- Title/Company 43e+ cor AitanceS GeoEnvironmewta ( <br />Print Na er Date 9 - Li— 0 3 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 5 0 <br />12-5z) /U. addik ///077 ç (JP <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br /> 0/C <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY INVOICE DATE _EUMIrTSERVI ---r# <br />3.501, 513, .5)9 - /040 17-1 j.f.- 9- .0035.573 <br />C-57 V WC V -WAIVER C-57 Letter of Authorization to sign p <br />1581478 <br /> <br />8/29/02 <br />