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el /1 g/T.'T.101 1B:@5 2094683433 FIFTH FLOOR PAGE 02 <br />AID# ACCOUNTING ONLY: <br />REVD BY DATE <br />6 ev ,(7 0 I <br />C-57 Letter of Authorization to sign permi <br />PERMIT / SERVICE REQUEST # INVOICE <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 />pplication 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 />oaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaouin County Public Health Services. Environmental Health Division. <br />fiti24,14 ff5S'y Assessoe_ <br />JELL Location MO Ai fll OW I/ Cross Street /4010411- City TO( erON zip q parcot Ofir/7 y -3e( <br />ROPERTY Owner44ie1/.1t/44111 (201.9118.74,5 Address 5-Y63 cefeleokee IA/ City 9rerdenvy Zip 5.--2-75---Phone# <br />City 1:egpoo- zip 0711-Liott 53-Yf71 Phone/ (946 s8 -7Z 71. <br />;consultant / Suiti-Coataaor Address 39/7 terce;eitt gd0 city el:0 Lia Phone# (f/.4f576/—OWO <br />3IS Coordinates: X , Y <br />YORK TO BE PERFORMED: <br />I NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUgH,(pAND-AUGE$_OTHER*) g DESTRUCTION (choose type below) <br />;oat_ BORING # <br />D OVER-BORE <br />U WELL # <br />a PRESSURE GROUT <br /> Grout Specifications. <br />30MMENTS: <br />;-57 Contractor 44-5/ /1)42111/fr-- Address 32-33 /-7"Zereiedt-/) <br />, Township Z 4/ Range 76- Section AR <br />TYPE OF WELL INSTALLATION TYPE <br />3 MONITORING ltOLLOW STEM <br />El EXTRACTION I] AIR HAMMER/DRIVEN <br />a VAPOR a MUD ROTARY <br />fl AIR SPARGE PUSH POINT <br />AOIL BORING U HAND AUGER <br />a OTHER: OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g/ MULTIPLE CASINGS? fl YES AKIO WELL CASING DIA: 4/4-- <br />CASING THICKNESS „,4"4— TYPE OF CASING: t] STEEL f PVC U OTHER: <br />DEPTH OF GROUT SEAL /oa f TREMIE TYPE TO BE USED: AUGERS El HOSE <br />GROUT SEAL PUMPED: g Yes jfi4,%Io (NOTE: MAXIMUM FE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 0 /1/4417 — <br />APPROX. BORING DEPTH /70 I] BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED'? Ai ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 4-8 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, dIes and egulations, and all applicable California State Laws. <br />Title/Company j;v7e-Tett/dr7e-011-- <br />-W <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: <br />Date Issued ( <br />0/ Final Inspection By Application Accepted By <br />-1101I <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS CONDMONS: <br />SR* 10:4 <br />oc 9/27/00 <br />Far* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # <br />C-57 WC -WAIVER <br />(A%-AAA_A r <br />(JA>Aitn,‘ Date <br />Date <br />Other: <br />SITE <br />MITIGATION <br />UNIT IV <br />Signed x <br />Print Name_ e5P41/1/7--- _/14M444 DEPARTMENT USE ONLY <br />Date