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WORK PLAN DATED: „).:\ <br />• <br />- ACCOUNTING ONLY: AID# FArl# • <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE EST # INVOICE <br />kr-12 J 11.- `-gl‘i -- C7L1/ (-1:' (4ALAA.e, 3/23/44-R# Doi35iO3-8-. <br />_ . . . r% I n -7 i r-1 n <br />C-57 Letter of Authorization to sign perm C-57 <br />V/ c. /,‘ via ncroac men WC -WAIVER <br />7> c.c.: (1" <br />Final Inspection By Date <br />Date <br />Application Accepted By L.,,C) <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued 3/ c:› I Area <br />Date <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 />Assessor's <br />WELL Location 7 9-9 1.2-4-/ Cross Street t'L kr4.6•44-1- City rAt--'1"--‘- Zip 9533 Parcel# I"T r - (7- 24 <br />PROPERTY Owner .4,3 /0, n oite- Address 4Icfdr1 1.-ky Cityfia,11--,,,,4=1. Zip 7.51)?Phone# 2-41 7 - Tr2i.3 ,c/r. <br />C-57 Contractor Pr; -5 Address 2 gc City/-' Zip99553 Lic# Phone# 9,2-5 -3/ 3-5,Fde <br />Consultant/Sub Contractor E'IS"4.4-54ddreSS z-cF P.-04-ic City P1,-) ti;/(4- Lic# Phone# 2-2.5 ")...3 97 <br />GIS Coordinates: X Y , Township Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />eSOIL BORING # c..77 2,--Z-/ <br />fl WELL # <br />*Other: <br />COMMENTS: <br />fi DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />a MONITORING a HOLLOW STEM <br />a EXTRACTION fl AIR HAMMER/DRIVEN <br />VAPOR fl MUD ROTARY <br />AIR SPARGE IT-PUSH POINT <br />fj4SOIL BORING a HAND AUGER <br />El OTHER: a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2'1/ MULTIPLE CASINGS? U YES B NO WELL CASING DIA: <br />CASING THICKNESS AM- TYPE OF CASING: fi STEEL fi PVC U OTHER: <br />DEPTH OF GROUT SEAL /V(' TREMIE TYPE TO BE USED: (k-AUGERS a HOSE <br />GROUT SEAL PUMPED: 114'es El No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ,4-4-“4-• <br />APPROX. BORING DEPTH ) C1 /- a BOLTED TRAFFIC BOX or fi STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /tie ( if YES, list specifications 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 Ordinances u s an lations, and all applicable California State Laws. <br />Signed x Title/Company Oper0/447/2-1. 6,ce-crat/idile <br />, <br />Print Name fe Pri44C/1- <br />Date 2 b/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1