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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ate Issued goi /7 2(.16) Area <br />Final Inspection By Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection <br />COMMENTS / CONDITIONS. <br />SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . JNIT IV <br />MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) cly <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 wei 4er <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 6;;?;7 0 ra_c_: A A Cross Street City ki`zr-zi Zip 1.1-.7c,'.7 Parcel# c -0Y <br />PROPERTY Owner Re C-2_,?e,rcv Address I )I<,. 7e- city SfQ.,1-1/4-'11.)-1-t. Zip erS-Wc,c/ Phone# <br />C-57 Contractor CI, Or; /4" Address q*J—c:' i</oce City i7 - th,./ r 2.: Zip fyrry Lic#Y-aCti,f;Phone# <br />B we* e <br />Consultant/Sub Contractor Fcfi.4 Address fc City Lic# Phone#2e-q. <br />GIS Coordinates: X , Y ,Township 2,1/Range Section <br />WORK TO BE PERFORMED: - <br />KNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />El SOIL BORING # a OVER-BORE <br />RWELL # i a PRESSURE GROUT <br />"Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />g MONITORING HOLLOW STEM <br />O EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR EMUD ROTARY <br />fl AIR SPARGE fi PUSH POINT <br />fi SOIL BORING a HAND AUGER <br />a OTHER: a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE t MULTIPLE CASINGS? B YES NO WELL CASING DIA: ;7 11 <br />CASING THICKNESS /7(c7 TYPE OF CASING: fi STEEL prPVC fl OTHER: <br />DVTH OF GROUT SEAL TREMIE TYPE TO BE USED: RAUGERS a HOSE <br />GROUT SEAL PUMPED: [J Yes fiNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: N C e'.-2-7 eel r <br />APPROX. BORING DEPTH RBOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? TV > (if YES, list specifications here): <br />"COMMENTS: <br /> <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 prepared this application and that the work will be done in accordance with San Joaquin <br />es app County Or 'nanc, Rules and Regulations, and all applicable California State Laws. <br />/ i 1, <br />:). <br />/ <br />---/' Signed x .4. g # ,_ Title/Company /7- z- 6t Ley, i i r/ (-'-r )e' L ,--- Zel---- 1' 4 / <br />Print Name 2--, <-.7 4'4, )<?--c„?,-.1--e_ Date ,S-r-----. C -,. / P : - 7 . - : , (D/ , <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AID# FAc# cROO t, 75-6 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT /S ' , : - - • INVOICE <br />C ' ' t •-rt-(-- v Ci : : E C7 <br />WELL PERMIT APPLICATION FORM <br />/c). <br />-WAIVER C-57 Letter of Auth izat o sign permit Encroa h ent doc 9/27/00 C-57 <br /> <br />WC