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, Township GIS Coordinates: X , Y Range Section <br />htoitt- <br />W C C-57 -WAIVER C-57 Letter of Authorization to sign permit . <br />WELL PERMIT APPLICATION FuRM <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 />WELL Location 11 Agz- Cross Street gal ste-t6ieSCity5-44.101A Zipq1.0;Z0L,- Parcel#,„_., <br /> <br />t.)- 2-5 <br />— Assessor's , a( <br />PROPERTY Ownert-eVv4-,.greVag/itI Address niZ i•)• Sv3c-D A1,r2- City-0.174440 Zip hone# <br />C-57 Contractor We31-- Oct z_ MIRT-Addres`F3315 ite462- Zr79:2Lic*P-41411honeePO 673B- 727(6, <br />Consultant/ Sub Contractor A.GE, Address ,,R31. aity-C-ilkOrtLic# Phone#ge l q6 7 /Qi <br />j:WORK TO BE PERFORMED: <br />W WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />VOIL BORING # <br />COELL # <br />*Other: <br />COMMENTS: <br />O DESTRUCTION (choose type below) <br />0 OVER-BORE <br />O PRESSURE GROUT <br />Grout Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 25/ndi MULTIPLE CASINGS? 0 YES du-fro WELL CASING DIA: / / <br />CASING THICKNESS 'TYPE OF CASING: 0 STEEL a PVC fl OTHER: <br />DEPTH OF GROUT SEAL -5f) TREMIE TYPE TO BE USED: ,a-A-UGERS a HOSE <br />GROUT SEAL PUMPED: U Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 1-,fr,R..-11.-e41,_6 ( <br />APPROX. BORING DEPTH I F5 reg-C-1---30LTED TRAFFIC BOX or El STOVE PIPE <br />, - , . CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <br />-e Mani L.1 &t.)Att. msi 4 4.//eA___ - crfe o_s_9.5RS144 '-ki-\-- A=1. <br />f>32__ iva--e.ii_ ett ek--/ .5-11=c4-4NR <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 />Title/Company <br />DEPARTMENT USE ONLY <br />afr(ez,azi lay\ <br />Date <br />Date <br />• -- ...... -..._. _ __..._ , <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT LSERV ST # INVOICE <br />55.-6 i - C — 9/94 /7/47 /44— /OP e. SR# 00 d---/(0/ 7 <br />. . <br />TYPE OF WELL INSTALLATION TYPE <br />ONITORING ea-POLLOW STEM <br />O EXTRACTION AIR HAMMER/DRIVEN <br />B VAPOR 0 MUD ROTARY <br />El AIR SPARGE fl PUSH POINT <br />O SOIL BORING fl HAND AUGER <br />fl OTHER: 0 OTHER <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Date g <br />SITE MAP IN UNIT IV FILE, ADDRESS: -7 ' <br />WORK PLAN DATED: 3-61.4A 2-ab 0/ teipproNe <br />Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br />vit.tfrutt-caftn.-, <br />Date Issued/Q///f/ <br /> Final Inspection By <br />60.-ev.-1.-t, r2.4... /L. e•P 5,4-r <br />Area <br />Date <br />Signed x <br />Print Name 7ka <br />SITE <br />MITIGATION <br />UNIT IV