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TYPE OF WELL <br />ONITORING <br />a EXTRACTION <br />O VAPOR <br />O AIR SPARGE/ OZONE <br />*SOIL BORING <br />(a OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM DIA. OF BOREHOLE t 0 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: `I <br /> <br />/ a AIR HAMMER/DRIVEN CASING THICKNESS2 t`3 5(°TYPE OF CASING: ['STEEL VC a OTHER: <br />O MUD ROTARY DEPTH OF GROUT Atc11241-k Pt) • <br /> <br />4680 / TREMIE TYPE TO BE U UGERS a HOSE <br />O PUSH POINT (GP or CPT)GROUT SEAL PUMPED: es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS Lif4AGOa 46-A 0 vtAAJc- --Ltyc ‘ I) ( 0 OTHER APPROX. BORING DEPTH —(40 )t, 6.; ISIOLTED TRAFFIC.BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED Nsi IA- (if YES, list specifications in comment section) <br />7 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />AfligtfAlitr <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By / r Date <br />COMMENTS / CONDITIONS: <br />(r) <br />Date Issued <br />nal Inspection By **NV Date <br />C- I <br />OOS Area <br />Date ,dee- /1/ <br />EHD 29-02-001 <br />6/22/04 <br />C-57 WC -WAIVER ion to sign permiti. Entroachment-Eiec--- C-57 Letter of Autho <br />Jan Joaquin County RE <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95292 <br />7 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sigoy,,org/ebd. 2oG5 <br />UNIT IV <br /> <br />,v41- I i511 Well Permit Application PERM1T 7 Li <br />/SER MEC' <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 i-AS kS. Wa.-er\co Vci I Cross Street Lkikcc‘i( P.City S4k Assessors )..) Zip q5-211Parcel# Oq 3-- 100 34 <br />PROPERTY, <br />Owner vul;‘‘ Ccrit-Vm fix/Address LI3‘.5- Llasi.\d-\\00 City 5\2(-V... Zip C‘5-21Z,Phone* q 3 I - 3ô 3- t-t <br />C-57 Contractor G-re_ f"‘A t‘tl; Address qSZ Oef)t-E" 2A cityUstkok2zipq 9553Lic#_16_1C-oneit Zs-) 313 -5-S0o <br />Consultant / Sub Cntr r‘st.tc /1/4A-21 Address g-c06 6:4.k6 SV. City ill Lic0(-4- tS12- Phone* ?o CÔÔ <br />GIS Coordinates: X <br /> <br />Township Range Section <br /> <br />27 <br /> ORK TO BE PERFORMED: <br />NEW WELL / BORING .(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # b r <br />ELL # S a *Other 17 <br />a DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />COMMENTS: 6 coA burv xi 01 Z. cAJ-a,z_t.0 ,p(4o <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordi ances, Ryles lid egul. .ns, and all applicable California State Laws. <br />Signed x j4l4J.jt Title/Company SE'N C Sc k:4t kiS\ <br />Print Name A- Date 2. 51 5— <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AID* (71T LI ---jVbet/ftVel ja4eOt y-t.Cie L.,((iikK CO /7 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D B DATE PE; ,, ers.-14a, EST # INVOICE <br />3 50 ( C( CO ( 6 6). (/ ? .,7- sRtoji-57 ía ,