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(hiA 0 BOLTED TRAFFIC BOX or ['STOVE PIPE <br />( if YES, list specifications here). <br />r <br />WELL PERMIT APPLICATION FRRM <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 /27 ...C7` Cross Street e7_,,OPt City Zip JAfrarcei# <br />7136 <br />PROPERTY Owner 9/i7' X._ Address Z 2/64° 44/4"t-4 City s57-r-A-) ZiAM?Phone# <br />C-57 Contractor a/Eg777.41-490'44--C-Addresi2Z1 /77X*44(/-11-kity444106 Lic# ,S.-t/91:4e(7/6A???-72•7,4) <br />Consultant/ Sub Contractor/4?:- Address 757 --c4auf 724( Lic# Phon4.40,944 7" /64‘ <br />GIS Coordinates: X <br /> <br />, Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />fl NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />U SOIL BORING # <br />U WELL # <br />/la-DESTRUCTION (choose type below) <br />0 OVER-BORE <br />'PRESSURE GRO <br /> <br />*Other: <br /> <br />Grout Specifications: <br /> <br />COMMENTS: <br /> <br />`COMMENTS: 41-A-6eA./ ii./4 244.0 01 <br />TYPE OF WELL INSTALLATION TYPE <br />i <br />tsplONITORING B HOLLOW STEM <br />fl EXTRACTION fl AIR HAMMER/DRIVEN <br />- VAPOR flMUDROTARY <br />AIR SPARGE U PUSH POINT <br />U SOIL BORING G HAND AUGER <br />OTHER: flOTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: [I STEEL B PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS B HOS4 <br />GROUT SEAL PUMPED: B Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />CONTCTOR CASING PROPOSED? <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 />Signed x <br /> Uk <br /> <br />a stit'oc, <br /> <br />Date Issued 2-5/CA, <br />-2-72/0 I Final Inspection By <br />Area <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Date <br />Date <br /> <br />Date <br /> <br />• <br /> <br />V ,.../11111•11-1, U _., r •,........•&.••• ••••••••••• <br />ACCOUNTING ONLY: AID# FAC# , <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE E REQUEST # VOICE <br />_ • . " I, -.1 i rw-% <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />I hereby certify that I have p_re ared this application and that the work will be done in accordance with San Joaquin <br />County Ordin es, R1iIes an egulatOs, and all applicable California State Laws. <br /> Title/Company <br />Date Print Name <br />DEPARTMENT USE ONLY <br />Aer—r <br />3—Z1- C I <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: