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Date <br />WORK PLAN DATED: 2 ?A/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: V&&/740,7-0-8- <br />Print Name ALAI_ (g. <br />Final Inspection By Grout Inspection By Date <br />Date Issued 0( Area <br />Date <br />Application Accepted By <br />WC -WAIVER C-57 <br />WELL PERMIT APPLICATION FO IM <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 [FlpMerit Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />_M <br />DpIL: Assessor's <br />WELL LocationOitW' pc,h) Cross Street6(aa , City57-6614_4"At Zip Y.Kal Parcel# O ci 2 -Zoe) <br />PROPERTY Owner Moat_ -re..,,L614_ Lugs Address PD. S Zip&e___Phone# t-4.-3269 <br />C-57 Contractor M(T.U4ELL.- L.LiAttr Address53e6 VA77 AVE Cit&it_-/-1-Lzip9s11-14, Lic#67210/7 Phone#(91) ‘,31 - 3583 <br />Consultant/Sub Contractor Crifi‘4lite0 , Address '3-1 SliAk) PAi> CitySick/a-iimi Lic# ZZ 7 Phone# 18.4 -166 6 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />7INEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />SOIL BORING # <br />ALW ELL # <br />*Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />A <br />g <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES fNO WELL CASING DIA: Z <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS OZO ' ' TYPE OF CASING: a STEEL XPVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-F.STAL aehi TREMIE TYPE TO BE USED: )1/AUGERS 0 HOSE <br />' 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: it Yes 0 No (NOTE: MAXI UM FREE-FALL DEPTH IS 30') <br />a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 17012_72-ANP -ryck Tr 77: <br />0 OTHER:El OTHER APPROX. BORING DEPTH 70 1 )(BOLT D TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 40 ( if YES, list specifications here): <br />*COMMENTS: 3 OU ALl) tAA-ree_ t14,0\1( 7-40 A1-6,- 1,14—a-C WS T2i1-4./2 -ro 7O' Bli:LatC Ss-l-V-F14&- <br />t.“2.400F. <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 prepar d this application and that the work will be done in accordance with San Joaquin <br />County qrdi les an ulations, and all applicable California State Laws. <br />Signed x 1D. Title/Company si-pF(-- a-kc,,ksT <br />SEP 1 2, 2001 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />O DESTRUCTION (choose type below) <br />OVER-BORE _c fl PRESSURE GROUT <br />Destruction Inspection By <br /> <br />Date <br /> <br />NS <br /> <br />ACCOUNTING ONLY: AID# FAC.# C c -Rori02 7Y <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> sR# . . <br />C-57 Letter of Authorization to sign permit Encroachment doc_