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, Township GIS Coordinates: X , Y Range Section <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE?(-3//)CA MULTIPLE CASINGS? YES 0 WELL CASING DIA: / 7'• <br />CASING THICKNESS TYPE OF CASING: 0 STEEL I] PVC 0 OTHER: <br />DEPTH OF GROUT SEAL -.'DIfIlee4c-- TREMIE TYPE TO BE USED: „ErgUGERS fl HOSE <br />GROUT SEAL PUMPED: fl Yes ZNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 'T-7-R.:Tt,15 ii/ cz <br />APPROX. BORING DEPTH I F57----tot,--r-e[r(30LTED TRAFFIC BOX or fl STOVE PIPE <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />Application Accepted By <br />Grout Inspection By Date <br />Date <br />WC C-57 -WAIVER C-57 Letter o u oriza ion o sign perm r_._ CnCrOW..rIriIrIi <br />WELL PERMIT APPLICATION FuRM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, 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 Public Health Services, Environmental Health Division. <br />Assessorss , f <br />WELL Location lq 12- isr ‘ 514117) Cross Street (41a ---e-e„LaCityCSCe-erfNA ZipTZOS: Parcel# )- 11 0 <br />PROPERTY Ownert-4("-..9reVaCVI''t t Address KtZt•S(Air-0 Av--- City-017(1"/k Zip /52,0-c-Phone# <br />C-57 Contractor /\)e-ii— HOZ- i\ikigrrAddres319 ,CitC <br />+2j2mi v oD <br />Zr-7:11-Lic#55-4illhonefil(0 638— 727t <br />Consultant / Sub Contractor AG& Address ta:37 -Sk4u.) Kekity-C-Lic# Phone#2b Li6 7 /0Z (e7 <br />ii.i/47 TO BE PERFORMED: <br />W WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />OIL BORING # <br />ELL # <br />CONDUCTOR CASIN1 PROPOSED? (it YES, list specifications here): <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 />Date <br />DEPARTMENT USE ONLY <br /> <br />Area <br />Final Inspection By Date <br />WORK PLAN DATED: a5 TaA 70b 0/ f4pprriv , <br />SITE MAP IN UNIT IV FILE, ADDRESS: 31)3.2- <br />Date Issued/40 <br />ez,Q1 ccjL <br />ACCOUNTING ONLY: <br />v <br />AID# 1 FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />5cai <br />1 <br />Eci- g#0, /79 *7. w- gli oi SR# ood--1(017 <br />. . . • , L 4. ..i...... Q/27/00 <br />*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />PRESSURE GROUT <br />Grout Specifications: <br />ONITORING <br />EXTRACTION <br />fl VAPOR <br />[] AIR SPARGE <br />0 SOIL BORING <br />Q OTHER: <br />"COMMENTS: gi532_ f_ect / "Cfr-cl <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />maid---4(24422 w86(_, )71,se <br />/01-10LLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT <br />O HAND AUGER <br />0 OTHER <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x ea,4_4A, Title/Company <-7-0(z) 4_c 4-67c <br />Print Name <br />SITE <br />MITIGATION <br />UNIT IV