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Section <br />GIS Coordinates: X Y , Township Range <br />Date Issued 311191 Area <br />Final Inspection By / Date Application Accepted By <br />Grout Inspection Inspection By Date <br />PE CODES FEE INFO <br />SITE <br />MITIGATION <br />UNIT IV <br />Joaquin County Development Title, Chapter 9-1115.3 and the <br />WELL Location 2.- FAST lAYPrie}1433 Cross Street <br />PROPERTY OwnerVali--/ caa _ Address 34)Wi7aelegert eicity cSlaP--4") Zip q5Phone# 166 567/(e. <br />C-57 Contracto 1 ' 4 I ill, ddressq60 i41-0g.e gd(.._ cityttite4Iarip 9/3Lic# 455/65Phone# t5 <br />q <br />- Consultant / Sub Contractor A.6 •-- Address 03-7 S(A_Ar..t.)e.Q. City S104.44ic# Phog q' #7 tib)6 <br />WELL PERMIT APPLICATION RAM <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 />f S aquin County Public Health Services, Environmental Health Division. <br />A City Zip <br />95/05 4srpsee;sors <br />t° SIX-e-i 5x <br />WOR 0 BE PERFORM <br />W WELL / BORIN <br />*Other: <br />COMMENTS: <br />°PROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />a WELL # <br />fl DESTRUCTION (choose type below) <br />OVER-BORE <br />[i PRESSURE GROUT <br />Grout Specifications: <br />INSTALLATION TYPE <br />fl HOLLOW STEM <br />fi AIR HAMMER/DRIVEN <br />MUD ROTARY <br />/FOUSH POINT <br />HAND AUGER <br />efrf)THER / <br />C177— t;4eeC7— <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 i/ MULTIPLE CASINGS? fl YES U NO WELL CASING DIA: <br />CASING THICKNESS _Al PE OF CASING: USTEEL [] PVC fl OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS fl HOSE <br />GROUT SEAL PUMPED: U Yes u No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />/60 BOLTED TRAFFIC BOX or fl STOVE PIPE <br />_QONDUCTOR.CASING PROPOSED? ( if YES, list specifications here): <br />.C(27 / 061)&4, _5' <br />TYPE OF WELL <br />fl MONITORING <br />fl EXTRACTION <br />VAPOR <br />- PAIR SPARGE <br />XolL BORING <br />fl OTHER: <br />*COMMENTS: <br />APPROX. BORING DEPTH <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <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 />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x LOS/ttikk, 05/Stk_ Title/Company etcp <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: r FT- IL° (7 5sitt <br />AID# <br />06-71 <br />C-57 WC -WAIVER <br />ACCOUNTING ONLY: <br />AMOUNT REMITTED CHECK # <br />FAC# <br />REC'D BY DATE 1 <br />1.tt< 11)ctiot SR# <br />1 PERMIT! SERVICE REQUEST # INVOICE <br />4222,s--67.? <br />r43. Tqc1cfa <br />C-57 Letter of Authorization to sign permit Encroachment doc • 9/27/00 <br />Date <br />Print Name Or) / kap.,