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GROUT SPECIFICATIONS SPECIFICATIONS U HAND AUGER <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 />WELL Location ,9-10 E6,5+1.4_,ek---Ancle, Cross Street iibliVt ".)-i-• City <br />A,33 , Assessors 0. Zi .49 Parcel* Z-7.4 - <br /> <br />PROPERTY <br />Owner C( Cl A/64/1 <br />C-57 Contractor ftAh <br />Consultant / Sub Cntr A-6E <br />Addressd-(0 ELi..-k---/hcrie S4 City r=vti-fZek Zip 91336Phone# ç-2305 <br />1 6 6 iq 1)/111 ci -22c -ouBty P--04 (.6 0 1\1-2 n Address Lic#6_220Phone# (9/6) 6 3 1-3.15 3 <br />Address S57 511 CAL,,/ VEY City5Lic#6g0).2-) Pho 11 4500 <br />GIS Coordinates: X , Township <br />WORK TO BE PERFORMED: <br />1,4sIEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />DI SOIL BORING # 0 OVER-BORE. DIAMETER <br />151/1/LELL # 'i? i)7,4 e. 4.,,MS 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br /> <br />Range <br /> <br />Section <br /> <br />TYPE OF WELL <br />D MONITORING <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 U HOLLOW STEM DIA. OF BOREHOLE n El MULTIPLE CASINGS <br />_.„ <br />MULTI-LEVEL WELL CASING DIA: I <br />U AIR HAMMER/DRIVEN CASING THICKNESS 5-fi CI° TYPE OF CASING: a STEEL IKPVC a OTHER: <br />a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes [p6 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />cp-tHo 9cfcte .i-911Ons (AA+ ek- <br />a OTHER APPROX. BORING DEPTH 0\ tc.cOLTED TRAFFIC BOX or LI STOVE PIPE <br />CONDUCTOR CASING PROPOSED o (if YES, list specifications in comment section) <br />S L.4 C.,f- pc pot-6cm( _ ,c-vt C-14.4 egari <br />°RINGS REQUIRE ACCESS AGREEMENT R'ENCROACHNIENT ERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />U EXTRACTION <br />a VAPOR <br />r-96IR SPARGE/ OZONE <br />0 SOIL BORING <br />0 OTHER: <br />COMMENTS: <br />NOTE: OFFSITE <br />i hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />Title/Company <br />ILE, ADDRESS: <br />6s marcc;„ a-00•1 ) qviecbvwci,w. wevt-r,e t-th6/cy <br />Application Accepted By (ie"e-tAAAt- <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# FAC# _ <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DAT INVOICE PERMIT! SERVICEq # <br />2c03`ft( ke & C , Or sl'utP0 3 3-1 / 3 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign per oath/neat-clot <br /> <br />9/30/02 <br /> <br />County Ordji,nces, Rule and_Regulations, and all applicable California State Laws. <br />5A-04 <br /> <br />Signed x <br />Print Name VP 1 avl .AA 1 /11 ovi Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV F 2- t C.) tA-)A-.4-14Aerk--_, , i rv \ c".41,4-c-,e,- <br />-7/ 0 v <br />WORK PLAN DATED: <br />Date Issued /o/e,y Area 17 ( <br />Date Cflio`r Final Inspection By Date 51/ Voi <br />Date