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p NA /NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />6S" []BOLTED TRAFFIC BOX or fl STOVE PIPE <br />GROUT SEAL PUMPED: I Yes <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />Area ape/ <br />Date 7-26.-O <br />Date Issued <br />Final Inspection By <br />/0-'1- -19 / <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> Date <br />Date <br />WELL PERMIT APPLICATION FORM <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 />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />orr I et) KOW <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 />WELL Location 2.3569 .S, ,C11 AlCk P.C1 Cross Street <br /> <br />City R kver6c‘. A k- Zip qr.36.7 PAasrcseels#slits-i4i '010 - <br /> <br />PROPERTY Owner L.SAINi4 CC", Address SJR.F. 1442.e1.144,‘ Ave . City T-Or...ttV_A Zip' GIS241)S- tone#1.2.130 — 3C1S-7 <br />C-57 Contractor G i'et5 11; Address Ll st) owe Pà. City /IGO-tit? z Zip SS Lic# 45r165" Phone# (412S)'.3 i 3—S100 <br />Consultant/Sub Contractor S an,s'rernAi NAildress 3o7 Ie- ;15o v_ t-41, Sie IQ.) CityRancik Ccra.c..4.1c# (102. Phone# it) V61-0900 <br />GIS Coordinates: X , Y .Township SC Range q 17S-gsi- Section <br />WORK TO BE PERFORMED: <br />));NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER.) 0 DESTRUCTION (choose type below) <br />}f:SOIL BORING # OVER-BORE <br />WELL # II PRESSURE GROUT <br />"Other: Grout Specifications: <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />fl MONITORING a HOLLOW STEM <br /> <br />EXTRACTION a AIR HAMMER/DRIVEN <br /> <br />fl VAPOR MUD ROTARY <br /> <br />a AIR SPARGE Ar.PUSH POINT <br /> <br />)fSOIL BORING 0 HAND AUGER <br /> <br />OTHER: OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2/1 MULTIPLE CASINGS? fl YES a NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: STEEL PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: II AUGERS X'HOSE <br /> <br />CONDUCTOR CASING PROPOSED? <br /> <br />( if YES, list specifications here): <br /> <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 />County Ordinances, Rules a d Regulations, and all applicable California State Laws. <br />Signed x Title/Company 5aCO ZIN riNti421 0 MAI <br />Pont Name e kt/G Date i'3101 <br />DEPARTMENT USE ONLY <br />ez <br />SITE MAP IN UNIT IV FILE, ADDRESS: SE-"P-4131 — <br />WORK PLAN DATED: 0/ <br /> <br />6 —oi• <br /> <br />COMMENTS ! CONDITIONS. <br /> <br />ACCOUNTING ONLY: <br />, <br />AID# <br />FAr# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 'D BY DAT, INVOICE <br />35S0 i 5 ; El ' Aostioi b .-22, - : ,i' <br />C-5 7 I WC -WAIVER C-57 Letter of Authorization to si n permit <br />ox— <br /> <br />SB 9lVd <br /> <br />JC10-1 <br /> CEVE89VEK -LE :ET CICIOZ/PEI/I