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Township <br />City Lic# Phone# <br />Range Section <br />Consultant / Sub Contractor locssoc... T.-AC-. Address <br />GIS Coordinates: X , Y <br />Signed x S. AielakILAN <br />SITE <br />MITIGATION <br />UN <br />FEB 0 1 2002 <br />SAN JOAQUIN COUNTY <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC FIFFIITH SERVICES <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 vyithltigillTN <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Assessor's <br />WELL Location 2.11-14 P-orvia.vw\ itt \je._ Cross Street C00.,k-Nt1 CA.49 City 5 -t-OC-r-COVN Zip C152.06 Parcel# <br />PROPERTY Owner C;,-,c.4 cD-C SiC0C—E.X0A Address Z5-0° \)- City 5-t-OC.L-Cdo Zipq52.0GPhone# <br />C-57 Contractor r)oc\wo.c-c\ Address City Zip Lic# Phone# <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type belv) <br />SOIL BORING # <br />I] OVER-BORE <br />;IiKIVELL # 1(11 03 -7 Cnne <br />0 PRESSURE GROUT <br />Grout Specifications: <br />COMMENTS: <br />*Other: <br />TYPE OF WELL INSTALLATION TYPE <br />XMONITORING *OLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />fl VAPOR fiMUDROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: flOTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS —, I <br />DIA. OF BOREHOLE ik MULTIPLE CASINGS? 0 YES A40 WELL CASING DIA: L- <br />CASING THICKNESS SL..V. Li 0 TYPE OF CASING: 0 STEEL XPVC fl OTHER: <br />DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED: „EL-AUGERS fl HOSE <br />GROUT SEAL PUMPED: 0 Yes 4yNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: --Re_y\k-tc_ 6 rc <br />APPROX. BORING DEPTH 301 wOLTED TRAFFIC BOX or 1:1 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N.) o ( 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 />Title/Company -13(0...V1/4.4_ YY\. <br />Date <br />Print Name DEPARTMENT USE ONLY <br />Area <br />Date Final Inspection By Date <br />Date <br />Date Issued (Co' 4zgz WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />COMMENTS / CONDITIONS. <br />ACCOUNTING ONLY: AID# <br />C-57 WC -WAIVER C-57 Letter of Autho <br />FA(' <br />PERMIT / SERVICE REQUEST # <br />iz ti' o sign perm <br />I <br />it Encroachment doc_ <br />\-1e <br />INVOICE <br />9/27/00 <br />A-s cL`te--S <br />I 3 (lo -z-- <br />_WELL PERMIT APPLICATION FORM <br />fl L5CF,HIE,DJ <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />FEB 01 200ZENviRoN MENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALN-i (209) 468-3449 <br />PERMIT/SERVICES