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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 />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />Oil elyieocu <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 />5., t Assessor's <br />WELL Location ,S°6co& ecfc, v--1( 40-e_ Cross Street RUji kit/04 City Sieb( Zip 95,9 7—Parcel# <br />PROPERTY Owner et.-f- of 5-10C klONN Address 'El 1,19,t-edv, City S HVYI Zip Phone#,AO '93 7 .15"'Z' 3 <br />‘A,N <br />C-57 Contractor 14(,1.) P` I / I <br />. <br />Address Ice 5--th 51-1-eet — letC77\ Zip956Y/Lic#W4*qhone# 9 >677 7 7- co„ <br />Consultant/Sub Contractor efr-ownebilazi/lits:ItAddressial544 Orty itY Lic#Se6:3`6Phone#7/YA -(>\ <br />GIS Coordinates: X , Y , Township Range Section <br />t") WORK TO BE PERFORMED: <br />%NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />[I SOIL BORqG # <br />lAWELL # hi) :----/77.47.)i <br />*Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />E:MONITORING 'HOLLOW STEM <br />fl EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />"COMMENTS: <br />CONSTRUCTION SPECIFICATIONS i f <br />DIA. OF BOREHOLE /0 MULTIPLE CASINGS1 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS schod Lido TYPE OF CASING: g STEEL ,PVC a OTHER: <br />DEPTH OF GROUT SEAL(01`" y 1 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: )(Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ee.41--ts--' <br />APPROX. BORING DEPTH a- /0 s %BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?A4, ( 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 />County 0 inances, Rules and Reg lations, and all applicable California State Laws. <br />Signed x 11-2t,t/t W n &01.05( S r Title/Company Ell_ U WY-) &-I li,,,,estfc/. 1 /11,11-• <br />-e vit H Medic PIN_ eV//3/0 i Print Name Date <br />DEPARTAIENT USE ONLY <br />‘'Ota -V <br /> <br />4 <br />Application Accepted By <br />Grout Inspection By <br />I AI r <br /> Date <br />Date Issued <br />Final Inspection By ETEEI:: --- / ge/ <br />"MIA' Destruction Inspection By Date <br />6 ‘.35.5 Aa0.1.A-Get ,/ . - / COMMENTS/CONDITIONS . etS ,'IZ-C-4 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P UEST # NVOICE <br />3c40/ /tea/ (5'47 3q-9-2_ Cat Z -13 5 R # O O 252%75 <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 2 -5-0/ <br />C-57 WC — -WAIVER --- C-57 Letter of Authorization to sign permit nc 9/27/00