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Application Accepted By <br />Grout Inspec'ion By <br />DeStructiOn Inspection By <br />Vs•A-a-4-1- <br />3/27/2B3 1:57 20E46834K FIFTH FLOOR PAGE 02 <br /> <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 INC <br /> <br />NON-RIIINDASLE_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 apolication is meCe in compliance with Ur <br />Joaquin County Deveiment Tito, Chapter 9-11153 and the Standards Of San .Joaquin County Environmental Health Department. <br />ASsessors <br />WELL Location2 G /5- .4 r ihrer Zoo Crosa Street /1/7 -0, City C7-W" Zip <br />PROPERTY Owner g e 5.eqe.'S 7., 057 Acdresa /7ea icil p / w 3 7-0-4 city /-7,4fp zip 913 0-pl,rie# '7/22 y( <br />C-57 Contractor f V Prv/7/75 Address/69 Y / 6" cilitta.-L., zip fr(glielnA1720P9Phona# cY/ 7,7 */04 <br />.vte-iiii Y <br />Consultant ( Sub Cnt -9,1 tagiC 47.ft/ Addressa 937 e'Ve•-h**2.1 City tiGefejeir Lict 112,8" 3 PhonaP 6-‘q serarc,a 73 <br />GIS CoCrdirlates: X `,/ , Township Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL BORING (CPT. GEOPROEE, HYDROPLINCH. HAND-AUGER, °THEW) <br />OIL BORING <br />a WELL f* <br />dari--15 4 COMMENTS: 2, <br />a 'Other <br />TYPE OF WELL <br />0 MONITORING <br />U EXTRACTION <br />0 VAPOR <br />U AIR SPARGE/ <br />p(SOIL BORING <br />a OTHER. <br />INSTALLATION TYPE CONSTRUCTKDN SPECIFNATIONS <br />AfelOLLOW STEM DIA. OF BOREHOLE ‘ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA oLti_Liff_ <br />fl AIR HAMMER/DRIVEN CASING THICKNESS //A TYPE OF CASING: a STEEL a PVC a OTHER: <br />U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO 3E USEDI,GIUGERS a HOSE <br />OZONE 0 PUSH POINT (GP or CPT) GROtr SEAL PUmPEO 4 Ye3 g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a HANC AUGER GROUT SPECIFICATIONS e--74, T .5' <br />g OTHER APPROX. BORING DEPTH(**1 / 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list spedfications In comment section) <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 Ordinances, Rules and Regulatl• .s, and all applicable California State Laws. <br />Signed x /* Title/Company h,-, _ <br />Print Mame _ 5 ril 1 it /il r <br />DEPARTMENT USE ONLY <br />ae r <br />/7. / <br />It <br />Date Issued /// 7-/d Area .F9. 7 <br /> Date C°/2142 1-1 _Final Inspection By <br />D <br />Date <br />ate <br />• -6(1 rh- __..._ _. . <br />ACCOUNT,NG ONLY: AID P FACit <br />PE CODES FEE 114F0 AMOUNT REMITTED a CHECK REVD I DATE BY 1 PERMIT I SERV/CE REQUEST $ INVOICE <br />(g_ ii / , SR# OD (:,(,(3 f <br />DESTRUCTION (choose type below) <br />fl OVBR-80RE. DIAMETER <br />PRESSURE GROUT , <br />GROLT' SPECIFICATIONSC/055 4rfe°40 7- <br />a55eT.5.5" ew <br />,F S (9s-0 <br />SITE MAP IN UNIT IV FILE, ADDR7 <br />--9- <br />5: <br />WORK PLAN DATED: A <br /> <br />C-57 Letter of Authorization to sign pert-tit Encrocchmcnt doc, C-57 W -WAIVER