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I hereby certif <br />County <br />Signed <br />Prin <br />, Rule Reg ations, and all applicable California State Laws. <br /> Title/Company Z,C e <br />that I have pre arecl this application and that the work will be done in accordance with San Joaquin <br />L37(_ <br />Date <br />DEPARTMENT USE ONLY <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit oochment doc <br />ACCOUNTING ONLY: NW( <br />FACII <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERM1 i•-•..-.-- -.---...: • EST # INVOICE <br />0. 0 551 2_ Cti .-- : : P. L <br />HEM\ <br />APR - 2, 2.001 <br />ENVIBONMENT HEALTH <br />PEPMIT/SERVICES <br />;-57 Contractor Address City Zip Li Phone# <br />Address City Licif Phone# <br />315 Coordinates: X Y , Township Range Section <br />NORK TO RE PENUMED* <br />] NEW WELL I BORING ( CPT. GEOPROBE. HYDROPUNCH. HAND-AUGER, OTHER) <br />XSOIL BORING # <br />WELL # <br />'Other: <br />'..s,OMMENTS: <br />:onsultant / Sub Contractor ,// t /4./ <br />U DESTRUCTION (choose type below) <br />[l OVER-BORE <br />U PRESSURE GROUT <br />Grout Specifications: <br />rypE OF WELL <br />] MONITORING <br />] EXTRACTION <br />] VAPOR <br />] AIR SPARGE <br />)SOIL BORING <br />(I OTHER: <br />INSTALLATION TYPE <br />D HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />U MUD ROTARY <br />.KPUSH POINT <br />IJ HAND AUGER <br />(;) OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIP.. OF BOREHOLE MULTIPLE CASINGS? fl YES a NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO DE-USED: 11 AUGERS D HOSE <br />GROUT SEAL PUMPED: [l Yes [l No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS. <br /> APPROX- BORING DEPTH a BOLTED TRAFFIC BOX or U STOVE PIPE <br />L <br />WELL FERMIlvAPPLICATION 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-REPUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />1pplication Is hereby madc to San Joaquin County for a Permit to construct and/Or install the work described. This application Is made in compliance with San <br />loaquin county Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />/2"r2 2 P- Cruss Street --Ifc City Zi 5f-7 r'1-1-'10 PAa5rciasels#Scril'r 31`11 \ NELL Location <br />'ROPERTY Owne ii(;)- VA, Phone# Address r Z741>0 City Zip • <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNI I- IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />SITE MAP IN UNIT IV FILE, ADDRESS! <br />WORK PLAN DATED: <br />Application Accepted Dy r Date Issued `A o / Area <br />Grout Inspection Date 41,0/(7 Final Inspection By J.J.S;tekktegreki,,A_____Date <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS. <br />SITE <br />MITIGATION <br />UNIT IV