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Migex1n,(;A\rbton\nuu ç. <br />DEPARTMENT USE ONLY <br />Date <br />WELAERMIT APPLICATION FIRM <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 />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 Divistii. <br />WELL Location VW/a oick Cross Stree t Ci <br />Assessor's <br />Zi(pit522 Parcel# WCJ • (Yin - Li <br />PROPERTY OwneaMpqmPkic.),(1,m- <br />C-57 Co n tracto*4 ak- Address <br />Consultant / Sub Contractor <br />GIS Coordinates: X . Y <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />ifitlEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) <br />44,KSOIL BORING # I — 3 <br />fl WELL # <br />El DESTRUCTION (choose type below) <br />OVER-BORE <br />[] PRESSURE GROUT - <br />*Other: Grout Specifications: <br />COMMENTS: <br /> <br />k.II OA <br />ddresR klOtbrD\ic LOCCIA C t 1 I. lin <br />/ ip t hone#CV),C) <br />oc,.../, it-) <br /> <br />City e uNr: (....7,VaZip l-)ILI )--"Licfr5St -fi I1VhonetiCU(c, ----7X/ L <br />TYPE OF WELL <br />[J MONITORING <br />[]EXTRACTION <br />fi VAPOR <br />[IAIR SPARGE <br />><SOIL BORING <br />[] OTHER: <br />*COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />XHOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? a YES a NO WELL CASING DIA: <br />fl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL fl PVC [J OTHER: <br />fi MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS HOSE___% <br />fi PUSH POINT GROUT SEAL PUMPED: fi Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS: <br />[] OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? <br />Ose. caw vra 2 . <br />( if YES, list specifications here): <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 />Countoydi.904:nances, Rulelled Regulations, and all applicable California State Laws. <br />Sign-.iS\Age5t5C— <br />C _ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Print Name <br />Application Accepted Byi*A-43:c'e <br />Grout Inspection <br />Destruction Inspection By <br />Area ID, <br /> Date (//2--7/1) / Final Inspection By Date <br />Date <br />Date Issued / 2i/ 0 <br />COMMENTS! CONDITIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PFMILSERVICEREQUES # INVOICE <br />3ro) 5ct - omp5/r--6 ilk_ ' 12-k? $R# 0 0 --(-1703 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit en 9/27/00 <br /> <br />Address5 eb <br />CO 39Vd <br /> aocr-u HII <br /> CCVC89126OZ TC:CT OOOZ/170/T