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ApplicaUon Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Final Inspection By <br />Date <br />06 Rr° Ira <br />-METE ate 7-24 -02— <br />Date Issued -6 2- <br />04/08/02 MON 12:54 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />ORIGINAt <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 />kION.REFUNQABLE 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 />WELL Location_ C 147/C 144 7--r,e AssesWs...q <br />Cross Street AAIW k.ot o t a00Zi 61(V Zip Parcel#1. - <br />PROPERTY Owner. bUNVIit. Addressl \si\ttl f2d CityL%_,RISI\JZIp Phone#Z2C -))11--2i <br />C-57 ConlractoA*4 Mkk--.N\.\\VeS-E.VCX .CI rA zi1;111t4) Lic#9,(0:624, phonee06-) - cOLgiq <br />GIS Coordinates' X Y Township <br />WORK TO BE PERFORMED: <br />/120EW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a SOIL BORING # <br />'WELL # <br />[j DESTRUCTION (choose type below) <br />fl OVER-BORE <br />fl PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL <br />XalONITORING <br />EXTRACTION <br />fl VAPOR <br />II AIR SPARGE <br />SOIL BORING <br />13 OTHER: <br /> <br />INSTALLATION TYPE <br />.-%111-1OLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />I] MUD ROTARY <br />fl PUSH POINT <br />['HAND AUGER <br />I] OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 9) kr\ MULTIPLE CASINGS? a YE4C10 WELL CASING DIA: <br />CASING THICKNESS 0. lb_ TYPE OF CASING: I] STEE.I..,--*VC 0 OTHER: <br />DEPTH OF GROUT SEAL --N• 50 TREMIE TYPE TO BE USED: a AUGERS [I HOSE <br />GROUT SEAL PumpEDA,85 rj No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />AFFROX BORING DEPTH --7P-(-- - 00LTED TRAFFIC BOX or 11 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list Specifications here): <br />(5.1.7 /so 4 brw <br /> <br />'COMMENTS: <br /> <br />Jazz-K. <br /> <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 a d Regulations, and all applicable California State Laws. <br />Signed 41111. 60111:18-1100— Title/Company 54-61PC CA oftt-i+ taw* r voteinliwn <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />(71 e/a*,e,(1.9r)- <br />- - / <br />U Z-4 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />-)f/- <br />ts4 op, <br />Consultant / Sub Contracto ddres?b/ C Di[we, ..."()3Liot 0. Phone# /1311,t0Y31,0 t-011 <br />Range Secljon <br />"Other: <br />COMMENTS: <br />Print Name Date <br />DEPARTMENT USE ONLY <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: <br />.. .... ......___... . <br />AID# cboa _ 7 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DAT/E INVOICE P z <br />3t) I Ailt4 W / 7-/ C/4/11 '/(Zg SR# °/. br;' <br />C-57 WC "/ -WAIVER 9/27/00 C-57 Letter of Authorization to sign permiii Encroachmtnfd-o-C