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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By gs.e„,c.I.(Date <br />Date Issued 9 -27 ( Area 66 e <br />• <br />Final Inspection By Date <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />UNIT IV <br />eas/to <br />WORK TO BE PERFORMED: <br />0 NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) (gpESTRUCTION (choose type below) <br />0 SOIL BORING # .OVER-BORE <br />WELL # /91e.c...r e mu/_ rPRESSURE GROUT C' <br />*Other: Grout Specifications: .?.5-4. froocnetWAI Z 5 .f-d gan 7441 i'IY- <br />COMMENTS: M5 e.rd/ be joieficiie 6.74 coo,/ Me4.14,,,V evei.-ba‘e <br />SEP 20 2001 <br />ENVIRONMEN f HEALTH <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 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 ... <br />. <br />rz <br />, <br />/ <br />.444 4(4 4 c-e-ocre Cross Street iiikel ki/ City $4.41c.• Zip -152 - 'li) Parcettt <br />PROPERTY Owner (-4 di. $4le-4., Address9, #11,Cii..0-1-44icity 544-1.... Zip Phonal.26Y '?71) <br />C-57 Contractor CC•ece,Zoold 1C -1//1" Address Po- go( Zgb cityg% -4,-- zp9q$7/ Lic# nao n phone#7a7 374i liticv <br />Consultant /6tib.Con4rastor te,e7.4041 a-• '4-7. Address 1 3 6' C 4" - -, gam** f74 cityata:AbiLic#5130 7 Phone# <br />'-'-- <br />GIS Coordinates X , Y , Township .2 A Section 2./" Range a •E <br />S-'• <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE U PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />a OTHER: a OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES B NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 13 AUGERS 0 HOSE INk. <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> fr,1 <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 Ordin,e, -s and Regulations, and all applicable California State Laws. <br /> Tale/Company (,4. P. o/o./.....4.4,166.451-4.. k , <br /> Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ' 2-5 AL Adyt-cr ao-C <br />WORK PLAN DATED: —C) t <br />-- ...... -..._. __.._..._.._. _ n_ <br />ACCOUNTING ONLY: AID# FACilt <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE IT! SER - <br />'7,66() 7 _ (.0•1 .LP(; C) - 5.3k. & CR ?- • : : 120 2q- 59 / <br />... I on -••• 1 11 " <br />\Air ..\/1/ATVFD <br /> <br />I ottor rt-f ittinriTrtfinn +n cinn norrni+ nrrevirhmoril• r4rr