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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED' <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />ate <br />ate Issued P-e c 2-7 , 2.6 a Area <br />Final Inspection By Date <br />C-57 WC -WAIVER C-57 Letter of Authorizat <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 />SITE <br />MITIGATION <br />UNIT IV <br /> <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 OQ 15Q 'CI- Cross Street PCIcki- SA-'1 400.'1 Zip Parcel# <br />PROPERTY Owner CA'}i (k))-- SA(sCI.Z-4-b‘A Address )2-5 A/ 1)0,1Q City 5-6L.10(-4'°-1 Zip Phone# <br />C-57 Contractor Ft.' k EAti Address ‘1"-Ls. City kildkkf 4 • Zip %.?-.S Itic# (153 hone# — 35 /1%3 <br />GA Consultant / Sub Contractor Ai C Address I -I- City A--04-)LG Lic# Phone# 5 °I - () <br />GIS Coordinates: X , Township <br /> <br />Range Section <br /> <br />*Other: <br />COMMENTS: <br />WORK TO BE PERFORMED: <br />il\JEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />1S'SOIL BORING # <br />WELL # <br />7\-^ <br />CA <br />Grout Specifications: <br />Ncr, <br />[j DESTRUCTION (choose type belov) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING Q HOLLOW STEM <br />EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR flMUDROTARY <br />0 AIR SPARGE kPUSH POINT <br />WOIL BORING fl HAND AUGER <br />0 OTHER: [] OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE V MULTIPLE CASINGS? YES 11.)48 WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: STEEL PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS fl HOSE <br />GROUT SEAL PUMPED: B Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />APPROX. BORING DEPTH <br /> 7_. 5 <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 OrdinancerfRules anCegulations, and all applicable California State Laws. <br />Signed x bAvv-.AA Title/Company A--CC tA-)S JZA-ttli-a <br />Date <br />DEPARTMENT USE ONLY <br />Print Name r)%1\t^^d \'ICky` A-6-ts". <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />AID# <br />AMOUNT REMITTED <br />Wod <br />CHECK # <br />FAC# 5R0o2Sli( 3) <br />INVOICE <br />Pe( 2 SR# aq <br />sign permit Encroachment doc 9/27/00 <br />PERMIT/SeTMCnTaGE;717; REC'D BY DATE