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.nni8jVip- 11 WELL PERMIT APPLICATION FORM <br />JAN 3 0 2002 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONMENT 1-1EAU1-1 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (209) 468-3449 <br /> SITE <br />MITIGATION <br />UNIT IV <br /> <br />ORIGINAL <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 Pudic Health Services, Environmental Health Division. <br />Assessor's / <br />WELL Location !SW 1...1 • 5 04t.A.J ilria-;) Cross Street VaitioNtr City 6 Tota re:Al zp(6- AC Parcel# / <br />Address VAD yat-iig-figr P-- • CIty 0-1A11-0 77ip.2it ti 3 Phone# • PROPERTY Owner ekIttlifkl1/41 (a:2 . <br />C-57 Contractor 'PI at ilk i.1- 'DUI Mgr Acidress34,0 c L011:77 i4A- City,SitiJA . Zipt-Ucit•Cilicl 7 phone#0 0 4.,1 -3583 .-- <br />GIS Coordinates: X , Y , Township <br /> <br />Range Section <br /> <br />Consultant / Sub Cantractor0- Citob,LviaiinI(AL Address 3 5../A1) bra ucitks',) z 1 Phone# 5/6 710 6 <br />WORK TO BE PERFORMED: <br />It NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />IL BORING (D <br />FELL <br />`Other <br />COMMENTS: <br />U DESTRUCTION (choose type below) <br />fl OVER-80RE <br />0 PRESSURE GROUT <br />Grout Specifications: <br />INSTALLATION TYPE <br />ti-HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />[l MUD ROTARY <br />[l PUSH POINT <br />[l HAND AUGER <br />OTHER <br />TYPE OF WELL <br />0 MONITORING <br />EXTRACTION <br />VAPOR <br />AAIR SPARGE <br />0 SOIL BORING <br />0 OTHER: <br />*COMMENTS: 0A-Ii• 1/4/-11-k- (-0144.11i1-10 VAlee- et(tkAl -Tiov cp.( F CfiraLifid JJftez.I; )(-7kial 72.4-/ <br />I 0 k..1.1_ A112_ 4A-CM i.,2k LL <br />CONSTRUCTION SPECIFICATIONS ,., ie <br />DIA. OF BOREHOLE 3 t' `'li/6e ' MULTIPLE CASINGS? 6-YES [l NC WELL CASING CIA: i- <br />CASING THICKNESS-54( qZ, TYPE OF CASING: [1 STEEL 23.-Pvc _ n OTHER: <br />DEPTH OF GROUT SEALVIZi "I• TREMIE TYPE TO BE USED: &AUGERS 0 HOSE <br />GROUT SEAL PUMPED: ,Yes a No (NOTE: MAXMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Pa_rukk-ID TyPi 1/7 (fAikpfr <br />APPROX. BORING DEPTH 1/0-14.114S VOLTED TRAFFIC BOX or a STOVE FIFE <br />CONDUCTOR CASING PROPOSED?X1C) ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. r <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 Ofilin nce,s, Rules and Regulations, and all applicable California State Laws. <br />Signed x d - Title/Company S'irPIE F Cr iL /A-i-vilidad i ii' 410 4'L'‘I I "-64 TA L <br />Print Name TAO. L._ -g . --6-1-,Suiv( Date 1-- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: / <br />Date Issued Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDMONS: <br />Final Inspection BP." Date Date <br />Date <br />ACCOUNTING ONLY: A1D# FAT-It <br />. <br />N\ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE p: • QUEST #\ INVOICE <br />0 / /tiai l • Ale2245 'AZ i 0 . 0 2.:3 <br />in r77/11() <br />C-57 WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit n <br />