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(11 <br />Date Issued <br />Final Inspection By Date <br />Date <br />CL5j,/ <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />ENVIRONMENT HEALTI- <br />PE.R Mr- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is haWy 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 ‘.//eii A./6gerige Cross Street A474/4/ City 576c.44-01 zip 'ZS-2a? ParceW e91 2‘o 2-7 <br />PROPERTY Owner PA • cialhIP7 hehlkol Address 6.257 MeAwsrlase A . city4 &ie., zip 9:74609 phone# 7a75.17 PIN <br />C-57 Contractor a c c c • i a 0 d Oillit Address RO. &X Y36 City/(4,4_ p'17/8"7/uctt 7/eb7c?Phone# 7,7 17/` Ii.,L10 <br />Consultant / 9b-Gontractat t-ties4.ft 64.- ay,Address ga,,Pit* P Cit"-eamv/gie6c#scs.5-7 phone# 5:Pccis? $300 1316 <br />GIS Coordinates X , Y Township .2_, A,. Range 4- Section 2/ ."-... <br />C , <br />WORK TO BE PERFORMED: <br />O NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER (choose ') DESTRUCTION type below) <br />a SOIL BORING # U OVER-BORE <br />0 WELL # / 2..RESSURE GROUT <br />*Other: Grout Specifications: 7 sk mA new( ules <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />1:1 MONITORING a HOLLOW STEM <br />0 EXTRACTION 1:1 AIR HAMMER/DRIVEN <br />()VAPOR 1J MUD ROTARY <br />AIR SPARGE a PUSH POINT <br />SOIL BORING a HAND AUGER <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES i] NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: ['STEEL Ei PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I:1 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br />0 OTHER: a OTHER <br /> CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 es, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company "5! 63144174,1 a'0,601 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />s E p 2 0 20 01 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />A tt)se/ 144i <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /11-5- <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />• <br />Date <br />e.' <br />ACCOUNTING ONLY: AID# FAC.# _ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PEEIALT / SERVICE REQUES INVOICE <br />..frept)2—tO ./ • " 5:38f 4(---5-20 SR# 0 02 5L5 0 .........,_ <br />r \yr -M/ATVPD r I ottor nf Au rflinri7ntinn tn cinn normit