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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />WA- <br />NE,CEiqE WELL PERMIT APPLICATION FORM <br />DEC 05 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 PERKT/SERVICES (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />Jogquin County Develqprnent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />k Assessor's <br />WELL Location St: at e-Vt.J r. Cross Street St; City St"tc-10-t•il Zip Parcel# 36 -2/o -- <br />PROPERTY Owner 5nt+e .../P Cal: 4. Address lioc• G-0 1.4 ci., •- e_ City Lio.-7/ aeRa-k Zip rA&...4 Phone# <br />C-57 Contractor Wo (...4..et..4 1•24 1:Pddress 5-45-0 fyp City /q;'o Visf rkZip 7/007 y Phone# ?s,7 - y - <br />.onsultant Sub ContractorCc.,4d0,,, C-scr•th Tech , Address /6e f4A-Lzeir g•e C ztAici/"C.i.colly Sib(-1-17v34..ic# Phone# 7 4/ -0 s-7 8 <br />, Township / IV Range Section GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />XWELL # <br />*Other: <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />fl OVER-BORE <br />0 PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING pgHOLLOW STEM <br />0 EXTRACTION AIR HAMMER/DRIVEN <br />1:1 VAPOR MUD ROTARY <br />O AIR SPARGE a PUSH POINT <br />U SOIL BORING HAND AUGER <br />0 OTHER: OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE e; " MULTIPLE CASINGS? YES KNO WELL CASING DIA: „2" <br />CASING THICKNESSTL,h V TYPE OF CASING: STEEL •K'PVC OTHER: <br />DpDTH OF GROUT SEAL TREMIE TYPE TO BE USED: g AUGERS 0 HOSE <br />GROUT SEAL PUMPED: ()Yes K No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: /lheor- <br />APPROX. BORING DEPTH 11 ,'BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? fy 2 c if YES, list specifications 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company j'n-r, (o_r_olyci;‘, [-A 12'44: <br />Print Name 1"."--e- Date :••7/ 2- =4 0 I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1' a -> f.) 14 Lk <br />WORK PLAN DATED: A Ac\k,,,A I 0 i <br />• <br />Date Issued 7-1 t> <br />Date /-2-7/41/ 61 % Final Inspection By Date <br />Date <br />Area <br />__ ...... _..._ . _ _.._ . <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE - : - Es UE : INVOICE <br />Iffinnillew4k MIL_ R#.9D,2-(,ct <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />