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WELL PERMIT APPLICATION ARM <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 9-111 .3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location ell i &C),L/61,-‘ eie 11)) 1 L.M"*L-)Cross Stre !to ' , • t . Cit3 Carlf.-V-V->" Zip 9 S-ZU ( Parcel# <br />0 1 ,..., Assessor's <br />PROPERTY OwnerL /fra,31„he I ... Ytt'elakiddress N"-tac)11,.% g-"11" R. cityweikik-tovl zip 4C Phone* Inc g 112 -- %Sr- <br />, <br />C-57 Contractorf !Ain rlit.5411-4 _Address TA.? _14-51A.4.4 14-WeCity114(Mbil Zip Cr15.53icdiallel-hone# pc----4.0-51w) <br />Consultant / Sub Contractor'6.--C-C,W cii(o - 0 I - 000 Address '3o11 ti\tect Ze) 4/10C1 City e Phone# 8 anaoCca. c)e1/4.$4# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />KNJEW WELL / BORING ( CPyEOPROBE, HYDROPOCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />[] WELL # <br />*Other: <br />COMMENTS: <br />[] DESTRUCTION (choose type below) <br />[] OVER-BORE <br />[] PRESSURE GROUT <br />GROUT SPECIFICATION <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2" MULTIPLE CASINGS? [] YES it*..9 WELL CASING DIA: <br />CASING THICKNESS THICKNESS 14104-• TYPE OF CASING: [] STEEL [] PVC [] OTHER: WA-- <br />DEPTH OF GROUT SEAL 0/Pi— TREMIE TYPE TO BE USED: [] AUGERS 4SE <br />GROUT SEAL PUMPED: J s Bili No (NOTE: MAXIMUM FREE-FALL DEPTH IS <br />GROUT SPECIFICATION ea‘-\-- Ceir—e__,A-t- <br />APPROX. BORING DEPTH OD' [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 00 ( if YES, list specifications here): <br />COMMENTS: 1...„7. \.7 <br />* CAJL TH ECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x 1 11 -› Title/Company kis .4..k. <br />Print Name '31SU a 0 C <br />SITE SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Date Issued I 10 0 / Area <br /> Final Inspection By CIIN-C14,1C04-1---- Date 5-- <br /> <br />Date <br />Date <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />,04F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PT INVOICE <br />3 Cc 1 5s,c,A , 0 0 cc)'f L‘tcy55 tt, P c/ / SFlit OD ?‘ '6 1 I i <br />TYPE OF WELL INSTALLATION TYPE <br />[] MONITORING [] HOLLOW STEM <br />[] EXTRACTION [] AIR HAMMER/DRIVEN <br />[] VAPOR [] MUD ROTARY <br />[] AIR SPARGE [] PUSH POINT <br />OIL BORING [] HAND AUGER <br />[] 0 HER: [] OTHER <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br />Date ztztlei <br />C-57 WC/WAIVER C-57 Letter of Authorization to sign permit trathmeatclae- 9/12/00 <br />