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WELL PERMIT APPLICATION RAM <br />2001 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ine\ Kr- NVIKNMENTAL HEALTH DIVISION (PHS-EHD) <br />J <br />0ie9.)Weber, Third Floor, Stockton, CA., 95202 <br /> ..../ (209) 468-3449 <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 />Cross Street Craortline Ad <br />Assessqrs <br />, City -1-c-a ci Zip qc3.76 Parcel# ;z3g -0go -07 WELL Location <;22.5.3 itb-fe 94...xxo. <br />PROPERTY Owner 1-bs Z5.. Address 3-Y6 0 1-0S+e_ Pil City ly- a cy Zip_g_...Phone# 0C-)q) 1.t,e_ -i-e_ ,e <br />C-57 Contractor GI' e N-)11 :/.1 Addressq-50 /400-/C. RS City 0164-ii) a Zip CH551 Lic# 4/q5/6--Phone#A72 c) 5 3 - 5-S00 <br />Consultant / Sub Contractor ALatice QGGA 1 i s Address (g 3'2 514 cw.) Roo) citym:ck-i:;#\\,//17:on 026'19% ? • /6)66 <br />GIS Coordinates: X , Y , Township <br />WORK TO BE PERFORMED: <br />„M'ange <br />FEB 2 6 201561 ).7 <br />Section <br />XlEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />*Other: <br />ASOIL BORING # 5- <br />0 WELL # <br />LIVVIRUINFIV / 1-ILALTH <br />' j] DE TR TION (choose type below) <br />a OVER-BORE <br />B PRESSURE GROUT . ‘ <br />COMMENTS: <br />Grout SpecificationA:_pL_R foi T/r,9: v, _ <br />\Y <br />..\.\ <br />TYPE OF WELL <br />MONITORING <br />EXTRACTION <br />'APOR <br />.IR SPARGE <br />5ttOIL BORING <br />U OTHER: <br />*COMMENTS: <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 Ordi ances, Rules and, gulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name tr i ain PA i) Liiczy) Date -c7)6 -C) / <br />DEPARTMENT USE ONLY <br />SITE <br />MITIGATION <br />UNIT IV <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS J` , ,)CES <br />a HOLLOW STEM DIA. OF BOREHOLE .:9 1‘ MULTIPLE CASINGS? fl YES a NO WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS /LIP( TYPE OF CASING: ['STEEL U PVC a OTHER: 0 <br />[I MUD ROTARY DEPTH OF GROUT SEAL Erv-il're- TREMIE TYPE TO BE USED: ,11 AMS a HOSE \IN <br />jeUSH POINT GROUT SEAL PUMPED: g Yes ,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') X <br />fl HAND AUGER GROUT SPECIFICATIONS: q(i) 4 ef.ck POr414.4 4-0 6,. NO AS t,-tor <br />0 OTHER APPROX. BORING DEPTH 60 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Itifr ( if YES, list specifications here): <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Sef+efri(oeir ,--?4 00 <br />C <br />Date <br />Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued MCKJI 5 Zoo) Area <br />Date Final Inspection By <br />• Le LJIIII WI C Pil I J I %ft/111111 'v.v., <br />,COUNTING ONLY: AID# FAC.# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # C./BY DATE PERMIT / SERVIU_ REQUEST # INVOICE <br />/L?35 I i 4 3 0.i frit oo <br />. .... . O PD "I MCI <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Author±cJfOn t sign permi <br /> <br />ncroac <br />