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WORK PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br /> <br />Date <br />Date <br /> <br />Final Final Inspection By <br /> <br />Area aF1 <br />Signed x <br />Print Name ec-.47c- (.2_„Aft,CA.X <br /> <br />WELL PERMIT APPLICATION FORM 0 ITtR. _I Pri-NAL <br />S — <br />MITIGATION <br />UNIT IV <br /> <br />SEP 20 2001 <br />ENVIRONMENT HEALTH <br />PERMIT/SFEWICES <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 />0A/AiA <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 61/125 /9,2c.,41 4enc-iE Cross Street 1)041744r A2c, City Sk•chicin Zip g..r2.07 Parcek# <br />PROPERTY Owner .Zi:/cco "AopeAVief Address 37C71 44(../#7 Ceek— City 5-isc4icol Zip 75.207 Phone# 20T 140 27/7 <br />C-57 Contractor6Voackaa ok,11,4y Address fA &-ec 3% City 435 (//).34 Zip q41.5-7/Lic# 741t,f7VPhone# 7°7 97vh9c° <br />Consultant /-S4413-Geotfeetorte,G,Ikhl kry1it iarAddress offsfi'avv,ex.1,. City61'ck,W44Zic#513857 Phone# <br />GIS Coordinates: X Township .2, /V Range F. Section 2-/ <br />WORK TO BE PERFORMED: <br />O NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) AIDESTRUCTION (choose type below) <br />I] SOIL BORING # ROVER-BORE <br />gWELL # MGe-, Mco2) km..03, mu> 1 j, m''# ?ø/O 'PRESSURE GR, OUT _ z_ <br />*Other: drout Specifications: 3 4n,c /2417Z deorta.16 /....,/ < 5- 7,1:7 10491/.6-4/7f- <br />(- <br />*COMMENTS: <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 />County Ordina as, Rules and Regulations, and all applicable California State Laws. <br />0,cfer1 <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: V2-5 <br />ACCOUNTING ONLY: AID# FAC# <br />I <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVIC' INVOICE <br />.--- <br />3902_ WI) 60 cc) S3 S'LF (./.--,,,A) ?-20 ( sR# <br />-M/ATUPD I ott or nf AI ithnri7n+inn tri cinn norrni+ nrrnnr mon+ rinr 0/97/nn <br />COMMENTS: AeOCOC -.14%V-vt4 Me4--• t Ccce4- -614e ( intx,2 rne-4,31" Mc(' /3 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />O MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? a YES a NO WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS I] HOSE <br />O AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />POTHER: D OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />Title/Company