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Signed x <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, I s nd Regulations, and all applicable California State Laws. <br /> Title/Company <br />Date Print Name C/ 74%—e <br />DEPARTMENT USE ONLY <br />C-57 9/27/00 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EEVESSVEK ES :0T 000Z/BT/OT ED EF..d <br />COMMENTS / CONDITIONS. <br />ACCOUNTING ONLY: AID # FAC# 6-1RCIE0021.16-- <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY INVOICE DATE PERMIT / SERVICE REQUEST # <br />35 D ‘ 4c\ 5 ( 6165; (-711'2e-- P-I 7 166 sR#0402 L/76-54 <br />—Saw <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 />SITE MAP IN UNIT IV FILE, ADDRESS: l S Turv1-10:44 ) <br />WORK PLAN DATED: 611.2--c3t.99 <br />Date Issued 1?-.1 -7 Area ct <br />Date ( 6 Final Inspection By C11 - • Date <br />Date <br />Application Accepted By <br />Grout Inspection By --nly\-• <br />Destruction Inspection By <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <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 /2// / 4,w/A /i<Cross Street 'CO Ple,eii-Cie_ City 74 1-7 Zip 9.c204Parcel# pr /-/G62-as <br />PROPERTY Owner Addressagi, ez‘ City S-4.4te5617 Zip 575-26g. Phone#‘20.45/4? y2,6, <br />C-57 ContractouAfkirch- n'/4.7 eor2kddress /lose 33 62 city /9;0 v:54 Zip 95/57/ Lic#7/0077phone(702)py-67, y <br />Consultant / Sub Contractor.* get 6474--qp,:vestddress /3 fG ,4-o7`XeGel•City et.voli-otic#.57.1115-7 Phone#(.0060-5.30a <br />GIS Coordinates: X , Y Township //a Range Section /r <br />N. <br />fl DESTRUCTION (choose type below) <br />OIL BORING # <br />WELL # /4/ <br />B OVER-BORE <br />y 0 PRESSURE GROUT <br />Grout Specifications: *Other: <br />COMMENTS: <br />WORK TO BE PERFORMED: <br />EW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g7/ MULTIPLE CASINGS? 0 YES ANO WELL CASING DIA: .1 " <br />CASING THICKNESS fc.4 90 TYPE OF CASING: fl STEEL ACIPVC 0 OTHER: <br />DEPTH OF GROUT SEAL $0 TREMIE TYPE TO BE USED: )AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: n P49es.7 4 .744 .577 oth <br />APPROX. BORING DEPTH 670 AOLTED TRAFFIC BOX or fi STOVE PIPE <br />CONDUCTOR CASING PROPOSED? A/0 (if YES, list specifications here): <br />&"") ""f -71724/ elL..ejtex — cc0 <br />TYPE OF WELL INSTALLATION TYPE <br />>r,D,IONITORI NG gHOLLOW STEM <br />I] EXTRACTION fl AIR HAMMER/DRIVEN <br />VAPOR U MUD ROTARY <br />AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING HAND AUGER <br />fl OTHER: flOTHER <br />*COMMENTS: