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TYPE OF WELL INSTALLATION TYPE <br />AMONITORING )(HOLLOW STEM <br /> <br />1B EXTRACTION fl AIR HAMMER/DRIVEN <br />LI VAPOR UMUD ROTARY <br /> <br />AIR SPARGE B PUSH POINT <br />0 SOIL BORING I] HAND AUGER <br />0 OTHER: fl OTHER <br />CONDUCTOR CASING PROPOSED? WO ( if YES, list specifications here): <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Jp). MULTIPLE CASINGS?YES 0 NO WELL CASING DIA:d <br />CASING THICKNESSSOKI 1/41(..) TYPE OF CASIN : 0 STEEL gt,vc 0 OTHER: <br />DEPTH OF GROUT SEAL EY TREMIE TYPE TO BE USED: 0 AUGERS U HOSE <br />GROUT SEAL PUMPED: XYAs 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATION: c•L41-011-( 1"Ce <br />p- APPROX. BORING DEPTH /6 C3 KBOLTED TRAFFIC BOX or U STOVE PIPE <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />off ,be-clef <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 n <br />Joaquin County Developmen Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location SI / c?CI r Cross Street (6bill L4:- City SibC fc-tbv"-- Zip ? r Parcel# lati —/(00 <br />PROPERTY 0Leri Li i D'ettli Lally e Address -5.4 ...tie_. City Zip Phone#a 0 V75 503 5 _ <br />C-57 Contractor Vrnd De-. ii; I Address 160 5 rk S -1:1-4 t --- cityl 5 I etryl zip 9 561 1 Li40:110Y phone#7 I 617 7 7 -YI ac ki ) <br />/1-q1/4(dtress /0064 Orflq 4-qty /9/C,CeMk Lic#406:38'--Phone#707Z 3...1 --(5-5-i N\ Consultant / Sub Contractorf vIVIteDYIles4P <br /> <br />\1 Range Section <br />WORK TO BE PERFORMED: <br />ItNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br />[]SOIL BOR G # B OVER-BORE <br />V WELL # tt)—c)(-/ 5717 B PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br /> <br />GIS Coordinates: X , Y , Township <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 ' ances, Rule and Re ulatioall applicable California State Laws. <br />010 Ft S FY/ kz>vt. t'Ve 1 4 it L Signed x Title/Company <br />Print Name Bisevit- tr Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 5(0010 p <br />WORK PLAN DATED: 2-5 -0 <br />Grout Inspection By <br />COMMENTS / CONDITIONS: <br />Destruction Inspection By -*----- <br /> <br /> <br />Date <br />Date Issued <br /> Final Inspection By <br />rea Application Accepted By <br />ACCOUNTING ONLY: AID# , FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE . INVOICE <br />'35 I AlA) 5/ 3V3 Ct4,14 2-13 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit iment docT 9/27/00 <br />