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ACCOUNTING ONLY: AID# - <br />REC'D BY DATE <br />Cak.A.n2— -1,4+ CA 0 44 k <br />FEE INFO <br />C jUr <br />PE CODES <br />-26C' <br />COMMENTS / CONDITIONS: <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perm <br />FAr.# <br />CHECK # AMOUNT REMITTED <br />SR# 0°A5 614' 1 <br />PERMIT_LSERVICE REQUEST # INVOICE <br />Encroachment doc 9/27/00 <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 Standarpls of San Joaquin County Public Health Services, Environmental Health Division. <br />Atcti '42 '11`109'' , „, Assessor's <br />WELL Location •".S-Fguil 1/pcilf UPty Cross Street t.>061( 1- City _7 44rieC Zip 9-533? Parcel# <br />PROPERTY Owner.,4,4,-7/ecc., f p <br />Address hi6e ted City -,e14/411/? Zip 9Y553 Lic# Phone# ns. - 3 13 -stay <br />Consultant/Sub Contractor /17-4 ,cret4C-e Address 2,Se tiVtdO City Pffildk Lic# Phone# <br /> <br />Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />Address 1001 1,i 604-( City ,,,-114,.-1"e5 Zip ?53)?Phone# <br />C-57 Contractor 12", <br />GIS Coordinates: X Township <br />(1 <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT. GEOPROBE, HYDROPUI)1CH, HAND-AUGER, OTHER') <br />SOIL BORING # -.2. a <br /> <br />0 WELL # <br />'Other: <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />p MONITORING p HOLLOW STEM <br />[]EXTRACTION fl AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />SOIL BORING p HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />L <br />CASING THICKNESS 4/4 TYPE OF CASING: [I STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEALVril clife, TREMIE TYPE TO BE USED: it AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: "Tick Cle-e-d --. <br />APPROX. BORING DEPTH c(10 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 4/4 ( 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, R lations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name t7rç 4Y ()E1€7t9•01— DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1,-*Vi k <br /> <br />clIsery,4 <br /> <br />Application Accepted By ci". ci\-- c-=CS-k-"I'00,- Date Issued 3/C--)1 <br />Grout Inspection By rb C 4-- Lo-, -c1/40-NrC'et,"\- Date Final Inspection By <br />Area <br />Date <br /> <br />Destruction Inspection By Date