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Print Name /11// //‘ $414-- ZA .77)€_.---' <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: C 7 1Z- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit V. bcroacflmeflT <br />WELL PERMIT APPLICATION R.,A111 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 0 <br />pERMIT/SERVUS (209) 468-3449 <br />Hr EVE <br />JAM 1 8 2002 <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 P ision. t) <br />ar .4 <br />5( ma Fr L,L(L t 7 <br />Cross Street k012:4 0-' 4116ity Zp6-)v` <br />, Assess°, 1 <br /> Parcel# WELL Location • <br />71/1 Address ..;e77L- City Zio l4eCF"-:1 Phone ). LC1)i ) 44-46 <br />P:Z.PiT 2 — liAttr4,710Z<at <br />(../ Address Y:31-Z—i•-i--2-H-4 City udt49'4'6?-plione e.k <br />PROP Ty Owner <br />C-57 Contract° <br />Sub Contractor Address ts?7 514.4.0,ek City —CAL lehil,Lic# Phcrie# 41'6 7 /66 <br />Range Section GIS Coordinates: X , Y <br />)7K TO BE PERFORM <br />EW WELL / BORING E PROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />OIL BORING # <br />a WELL # <br />*Other <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />[3 OVER-SORE <br />[3 PRESSURE GROUT <br />1\1 <br />\ <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 i'-:• 4- MULTIPLE CASINGS? [3 YES [3 MG WELL CASING DIA: <br />CASING THICKNESS itill- TYPE OF CASING: [3 STEEL a PVC a OTHER: --Z <br />DEPTH OF GROUT SEAL 017e4-6I TREMIE TYPE TO BE USED: [3 AUGERS [3 HOSE <br />GROUT SEAL PUMPED: ..]:1-res 0 No (Nftl._ MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: /522;•44 _ a- .B4741L .;- <br />/(3=0 APPROX. BORING DEPTH '-'7.5 F'1 7-f-] BOLTED TRAFFIC BOX or <br />CONDUCTOR CASING PROPOSED? itrA— ( if YES, list specifications here): . <br />TYPE OF WELL <br />a MONITORING <br />EXTRACTION <br />a VAPOR <br />a AIR SPARGE <br />"OIL BORING <br />0 OTHER: <br />COMMENTS: <br />INSTALLATION TYPE <br />a HOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />MUD ROTARY <br />USH POINT <br />a HAND AUGER <br />S.5) Roy — Zi ST <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 A 6 - <br />• <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DAT PERMIT / SERVICE REQUEST # INVOICE <br />?----0 / 7 fìØz- sR# 2 - c id-7/m <br />, Township <br />Date <br />SITE <br />MITIGATION <br />UNIT IV <br />RIGINAL <br />Grout Specifications: <br />STOVE PIPE <br />Date Issued Area <br />Final Inspection By Date Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date