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Date <br />Date <br />It <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /-2/4,0 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS <br />Date Issued /7 -0 / <br />Final Inspection By te <br />tW53(z, ,04 <br />ea ag <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 />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 />City S DOACi ZiP159.61 PAasrcs:17Pes <br />Address City %kirk:ken ZifNaPhonet*C1S1 -ChaFt Stra_A-.6y-N ekt'llf 'k-ket <br />C-57 Contractor <br />0 <br />Consultant/Sub Contractor .rr„ Address 3011 N jeo City 12-c,_ciAv'43cf_k.... 0 <br /> <br />GIS Coordinates: X Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER.) <br />fl SOIL BORING # <br />7c..VELL # 04012. tAvlet <br />SITE <br />MITIGATION <br />UNIT IV <br />prE/a5 <br />WELL Location!) <br />PROPERTY Owner ti <br />84T) <br />Cross Stree <br />Address .'olleowe Zi P -1-ic641$4.5Phone#1.2.$ -31358C0_,, <br />Lic#65 ,pr7b Phone# 9 I (0--?,tok -Nov <br />*Other: <br />COMMENTS: <br />Grout Specifications: <br />a DESTRUCTION (choose type below) <br />fl OVER-BORE <br />a PRESSURE GROUT <br />(11 TYPE OF WELL INSTALLATION TYPE <br />MONITORING2f;C;.LLOW STEM <br />fl EXTRACTION a Al HAMMER/DRIVEN <br />VAPOR [J MUD ROTARY <br />AIR SPARGE fl PUSH POINT <br />fl SOIL BORING fl HAND AUGER <br />U OTHER: U OTHER <br />'COMMENTS: cee <br />CONSTRUCTION SPECIFICATIONS <br />i` DIA. OF BOREHOLE MULTIPLE CASINGS? U YES 0 WELL CASING DIA: 2 <br />CASING THICKNESS CSe..‘A LIO TYPE OF CASING: [J STEEL *VC I] OTHER: <br />DEPTH OF GROUT SEAL (-). Ito( TREMIE TYPE TO BE USED: fl AUGERS .--IOSE <br />GROUT SEAL PUMPED: alles a No (NOTE: MAXIMUM FREE-FALL DEPTH I 30') <br />GROUT SPECIFICATIONS: ts.)e,cark- C e'42.$ <br />APPROX. BORING DEPTH LI 1:23/42sLTED TRAFFIC BOX or fJ STOVE PIPE <br />CONDUCTOR CASING PROPOSED? i\NO ( 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br /> <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT RowtrrED CHECK # REC'D BY DATE PER QUESN INVOICE <br />3,5Di kak) ?Yi ' 02.73 2- -14 '7 -. • 2•536 / <br />Title/Company <br />6T0k-f,‘A \r)WiS <br />DEPARTMENT USE ONLY <br />i\e`f-AA-os‘k OAV tc* <br />Date ‘2,RD <br /> <br />-WA <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />9/27/00 <br /> <br />39Vd aop-u HtdI EEVE891760Z TE:ET 000Z/120/ZT