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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 11 1 1 IC) (.) <br />Application Accepted By <br />Crout Inspection By <br />Destruction Irsoecticn By <br />t,,Ot iSOn Wel <br />Date Issued <br />Date Final Inspec:Ion By "f/A Cate P- PA I 6 ( <br />Date <br />Area <br />COMMENTS / CONDMONS. C OT - C - t <br /> <br />Cr3.,/1 -3 frAd' <br /> <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH blVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 • <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 r lade in compliance with San <br />Joaquin County Development Title, Chapter S-1115.3 and the Standards of San Joaquin County Public Health Services. EnvIror rental Health Division. <br />Assessor's <br />WELL Location /OZ S. 4)//56,z, Cross Street 7mekel CIty Stlx..Wfdal Zip Parcells <br />PROPERTY Owner ,061:0 44e4 Address '{ 3f367( atvSieck-L..% Zip Phone; 40-1 83(9 <br />C-57 ContractorWej Acttsij Address 41 tist•-ISC Sf ItySts )i?•44f Zo VIC161 L c# 3441 FnoneS c/a) 7,r7-45-75 <br />Consultant I Sub Contractor /Ana 2-cry Address/ 7/e/ 4197;ci City?Zetekr- Phone <br />013 Coorcinates: X , Y <br /> <br />, Township Range Secret. <br /> <br />W T BE PERFORMED: <br />EN WELL BORING (CF GEOPROBE, HYDROPUNGH, HAND-AUGER, OTHER") ] DESTRUCTION. (choose type below) <br />ArtOIL BORiNG 6PT OTZ, CR/ a CVER-BCRE <br />WELL # 0 PRESSURE GROUT <br />'Other Grout Specifications: Weal- cop...tii <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING 1:1 HOLLOW STEM <br /> <br />1] EXTRACTION r, AIR liAMMERDRIVEN <br /> <br />a VAPOR MUD ROTARY <br /> <br />SPARGE ROUSH POINT <br /> <br />.00IL BORING [I HANG AUGER <br /> <br />OTHER: 11 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 7 1/41' MULTIPLE CAS NGS.7 D YES ZINO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING a STEEL fi PVC [OTHER: <br />DEPTH OF GROUT SEAL/fa t GO TREMIE 7-YzIE TO BE USED: ['AUGERS kr<OSE <br />GROUT SEAL PUMPED: ,(es [No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS:AA/ 044.1.a5igki- <br />APPROX. BORING DEPTI-1/(0',6 CO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( f Y!3, list speu.ficaticns here). <br />*COMMENTS: <br /> <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 Or es ules and Regulations, and all applicable California State Laws. , <br />0/oyi'P <br />Sio <br />. _ <br />ACCOUNTING ONI.c.-1 <br />_ _ ... <br />AID# <br />, <br />FAGS <br />.i• <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE INVOICE ERMIT / SERVICE-I:MOUES • <br />o i .. <br />C-57 <br /> <br />WC -WAIVER <br /> C-57 Letter of Authorization to s1911 licrciddinient doc 9/27/0 <br />SITE <br />MITIGATION <br />UNIT IV <br />Signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />444 C; E )" <br /> Tit &Company <br />Date <br />ge'D-E,2A4 Zero