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Date <br />Date <br />Area -00 <br />Date <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <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 />Assessor's <br />WELL Location -51 S. I 14447,/c AfvEA'c'e Cross Street A.00 /4/441°41 City -5-7 e14:k"Al Zip 9S 20 7 Parcel# /40 5.-/*09 -0/ <br />GOLZO-40. Z09 <br />PROPERTY Owner SAN OA P/A' 404ctr4 Address -S741/4". ,4-5- (-A/Art City Zip Phone# 95q- 55" <br />915 <br />C-57 Contractor dice C ZIV / Address 9 50 itietve ift04.40 City Afelgr/iVEZZip951.533Lia#4 7hone# 3/3 -- -5-7° ° <br />Wit( <br />Consultant/Sub ContractorEWKACIW/M-ivr-Af dv0 /Xadress /000--( aere 4-4 i•-bI tity P10442-^117 lic# 406551,Phone# 6-31" Ir5.4/ <br />GIS Coordinates: X , Y <br />WORK TO BE P <br />GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />.4 0 WELL # <br />1, 2, 3 "--VGrout Specifications: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U MONITORING <br />[)EXTRACTION <br />VAPOR <br />[] HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />O MUD ROTARY <br />DIA. OF BOREHOLE MULTIPLE CASINGS? fl YES [1 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: fJ STEEL I] PVC OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS HOSE <br />AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />OSOIL BORING O HAND AUGER GROUT SPECIFICATIONS: <br />[] OTHER: 0 OTHER APPROX. BORING DEPTH [1 BOLTED TRAFFIC BOX or []STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <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 Ordin nces, Rules nd Regulations, and all applicable California State Laws. <br />Signed x Title/Company•41:"'ee:/04`-'1'7"7.4-/Vv4e°A415A/77.44 ,4'-' '7 <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: —5-00 07 5606 <br />WORK PLAN DATED: <br /> Yie-4-1-e-e- <br />43/ ice.° - <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 P - - • 11- . # INVOICE <br />3501 zekpr- .tal --- 039- S alt II- 2. --Gstmt-‘ R# W 2M-7-5 <br />SITE <br />MITIGATION <br />UNIT IV <br />, Township Range Section <br />*Other: <br />COMMENTS: <br />NEW WELL/ <br />igkazi 4.146r41 stm4. <br />DESTRUCTION (choose type below) <br />OVER-BORE <br />0 PRESSURE GROUT <br />7ite/Y•6 A-A(7/Y 7Witi"ffiVe1'-r-ieTA/ <br />El' 77/ <br />TYPE OF WELL <br />Date Issued <br />Final Inspection By <br />C-57 V WC -W AIVER C-57 Letter of Authorization to sign permit sZ FhTrFff6ciA.èof 9/27/00