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TYPE OF WELL <br />)(MONITORING <br />EXTRACTION <br />AIR SPARGE/ OZONE (KPUSH POINT (GP or CPT ROUT SEAL PUMPED: <br />SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 4/7 6-7 ,"4" 16'V7 <br />[]OTHER: a OTHER: a OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or STOVE PIPE <br />VAPOR a MUD ROTARY <br />INSTALLATION TYPE <br />Ll HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE •‘- a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: STEEL a PVC a OTHER: <br />AUGERS a HOSE <br />a Yes (KNo (NOTE: MAXIMUM FREE- ALL DEPTH IS 30) <br />DEPTH OF GROUT SEAL /(--(..LL - 7,7 TREMIE TYPE TO BE USED: <br />(04 ee C,4:1 1_/1/6.1/2. <br />RECD <br />AUG 4 SiTE 0 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 20.46TIGATION <br />W (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/e VIP p UNIT IV PERmaisco 'EA tri-i <br />Oi9 r24A41A(- <br />.._ <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 complia ce with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 7320. /1/ 64zbc:: 57- Cross Street P/4 / City -,10644"701/fi Zip Y.> Xi•-)47 Parcel# <br />'Assessors j7c-- 2CiPA _ <br />PROPF--" E8 s3 <br />Ownei. V0145/1 ,ddress ACORNI • 5 T ,city5-r6c/rci z052/2phone# r <br />C-57 Contractor 1:414/71/4- Address Yszp 4h.ve-74,4e, city /t1m2,7,44egip 94,0- 3_ic#6.‹.-/w a, Phone#574r 3/3 007f, <br />Consultant / Sub Cntr Arerk//a. gleZ . Address 411e2 c64-/ AGYreeityhtffe2e/Kic,# 770 7 Phone# 9?/ef, <br />sf-7 <br />GIS Coordinates X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />ig'NEW WELL / BORING <br />,,SOIL BORING # <br />WELL # <br />0 *Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) ,DESTRUCTION (choose type below) <br />' [LOVER-BORE. DIAMETER <br />) „PRESSURE GROUT <br />(GROUT SPECIFICATIONS_ <br />COMMENTS: <br /> <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Environmental Health Department <br />. q San Joaquin County <br />RIGINAL <br />CONDUCTOR CASING PROPOSED <br />COMMENTS: c6 At -7- 7-4 cfreeo <br /> <br />(if YES, list specifications in comment section) <br /> <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Title/Company L.-;/ 1// <br />Print Name 41046- 17 -4 A Cfr-i Date C7C.ei <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE T # INVOICE PERMli / SERVICE RE <br />- 5 - 0 t — <br />-5017 ---22'S <br />Cs1 _.II t`15 i <br />\ \ 3 ' <br />fy .., <br />(Ah'I`. F.k1 <br />(..,_ SR# ,467?6 5 <br />C-57 WC %/-WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit <br />6/4C-e,>4-• <br /> <br />Signed x <br />DEPARTMENT USE ONLY <br />2315 Ai. z iV <br />Date <br />Date Issued <br /> Final Inspection By <br />Date