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SITE MAP IN UNIT IV FILE, ADDRESS: A) <br />WORK PLAN DATED: <br /> <br />Date <br />Date <br /> <br />COMMENTS / CONDITIONS <br />Application Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Area <br />Date <br />Date Issued <br /> Final Inspection By, <br />,e9t <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 />sn-DRIGINAL <br />MITIGATION <br />UNIT IV <br />Off: <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 i 6 '(5 1 5- c-Aln 31'-'3L)-1: Cross Street L 661 tit) City --rb 'zip <br />PROPERTY Owner 14u-'-' t(DIAILLIP-S Address I SI <br />'Yvka;*4 e-I 0-0 -city ( Zip 15336 Phone# <br />C-57 Contractor 6s04 EA)°,46ASICA-TftAddress 211 SOX:g-IS <br />3002 <br />etAt city ,-S zipq 5754ic# Phone# Z`" N"2- 35-)) <br />. c City (-13/0-14* Lic# Phone# <br />icst.stue gAN_ <br />t2A.`"" 6'594 41 fr Oki0a <br />6 43-38-65- <br />S Fr ° <br />Range Section <br />fi NEW WELL/ BON,( CP1OEOPROBVHYD103,0pUNCH, HAND-AUGER, OTHER") <br />WORK TO BE PERFORMED: ,- <br />fl DESTRUCTION (choose type below) <br />SOIL BORING # <br />0 OVER-BORE <br />0 WELL # <br />fl PRESSURE GROUT <br />*Other: Grout Specifications: vri.c <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 9 YES 0 NO WELL CASING DIA: '&•744- <br />CASING THICKNESS 1"-"'` TYPE OF CASING: fl STEEL UPVC U OTHER: ik"k- <br />DEPTH OF GROUT SEAL '1/4"\e'' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: fl Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: "4." <br />APPROX. BORING DEPTH I S El BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? " ( if YES, list specifications here): <br />*COMMENTS: <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 SiNeVri; C)e-bt" f*'Ci -1457-E4k-4-1A-TI "-)L <br />Print Name 1-141DAAISS PAit-v.-.01 /4 __ Date 'iJif 1/ 0 <br />DEPARTMENT USE ONLY <br />Consultant / Sub Contractor <br />GIS Coordinates: X ,y <br />Township <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION I AIR HAMMER/DRIVEN <br />g VAPOR UMUDROTARY <br />0 AIR SPARGE El PUSH POINT <br />TISOIL BORING U HAND AUGER <br />B OTHER: UOTHER <br />ACCOUNTING ONLY: <br />a <br />AID# <br />. 0' <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT/ ELI E REQUEST # INVOICE <br />523, Ci--- 5. 3 spit 06 2.-. ? P.W ----- <br />C-57 ,4( WC V -WAIVER <br /> <br />C-57 Letter of Authorization to sign per 9/27/00 <br />