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Title/Company Signed x <br />Print Name DEPARTMENT USE ONLY <br />I 5+ <br />Date ))/i/G) <br />7']/`\ <br />Date Issued k I <br />Date I t 120(0( <br />Date <br />Application Accepted By (i1\.-t 4"4" e,t,"‘ <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Area <br />Final Inspection By j>ruvvicr,r--..._ Date elC% <br />WELAERMIT APPLICATION F _ <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />NOV 0 9 2.001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />_ 304 E. Weber, Third Roar, Stockton, CA.., 95202 • (209) 468-3449 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a perrnit 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 Pudic Health Services, Environmentai Health Division. <br />. . - Assessor's <br />WELL Location 10- (.0„2_,/), 6;biru-ct 5•1-, Cross Street (Xtrk 51-, City 9ACk-.1"..1vil Zip 4754-°, Parcel# <br />PROPERTY Owner C-, a VI S a COOT P`l Address / 0 50 5,-) 1 1 1 Jen city 3 --0(-6-i ,p 1S1-0 5 - Phon ;)0(() Yi ll -/.2 2. .,S1.- t ),-, zi i7 <br />C3 5-(' 4Ci tk 2-0 CltY l'AP141,) ZiP614 ) >Ljait ("50-10? Phone:402 c)/14.5161) <br />r ., ) <br />Consultant] Sub Contractor 6--b" Address `... ? ) c)k "— 14,1 City 5-6 l'-f-C)ill Lic# (.)2--) Pficnelic..-2-0 )1-/6-2 le)66' <br />GIS Coordinates: X , Y , Township Range <br /> <br />SeoPon <br /> <br />WORK TO BE PERFORMED: <br />"L•NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HOD-AUGER, OTHER) <br />ItSOIL BORING # crr <br />II WELL # <br />'Other. <br />COMMENTS: <br />C-57 Contractor L-).,reY) -5 ri• Address <br />fl DESTRUCTION (choose type below) <br />fl OVER-BORE <br />PRESSURE GROUT <br />Grout Specifications: <br />INSTALLATION TYPE <br />a HOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />MUD ROTARY <br />.;ECPUSH POINT <br />HAND AUGER <br />ri OTHER <br />TYPE OF WELL <br />(]MONITORING <br />Q EXTRACTION <br />a VAPOR <br />AIR SPARGE <br />OOL BORING <br />OTHER: <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. CF BOREHOLE ,.‘` MULTIPLE CASINGS? a YES a NO WELL CASING DIAk/4 <br />CASING THICKNESS 70LA TYPE OF CASING: a STEEL U PVC a OTHER: <br />DEPTH OF GROUT SEAL ECI-1-; TREMIE TYPE TO BE USED: VrEirtSL a HOSE <br />GROUT SEAL PUMPED: ,Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: `Thl 12014 v'cW Ci)/ 6eifiC HZ' <br />APPROX. BORING DEPTH i a BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? AJA ( if YES, list spedfications here): <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 Or inances, Rules yIci Regulations, and all applicable California State Laws.. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 7C _c;c:;\--c,1,-, :?co( <br />LUIVIIVIMNI I a, tounut I itit....,. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT I SERVICE REQUEST # INVOICE <br />35-of 4ir 9 s 00 I c133 V fillbto SR# <br />- npr7inn <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit bcroocflmeflT - <br />ik6 '2:kW&