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MITIGATION <br />UNIT IV 1)0 eD-6piiqufv-) Date Issued <br /> Final Inspection By <br />Date <br />7*4/4/7 vaiza( <br />Date <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is her by 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 />Oupionment Title. Chaoter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />at_ Assessor's <br />WELL Location i U.;? t it). <br />' City .:)- (.14444-0-4,4A/Z Cross Street L'' Lifil+/C3f Zip fj Parcel# ,,,J- e AA tt '4,e, 1"i <br />-3.4..Le-- <br />PROPERTY Owner Owner C \-1'1 0I Address Address .^-)-b-- City 4-lhe Zip ''') 41*- Phone# A <br />C-57 Contractor .,.. -,, fesss,9 SEv"IS eLAc-v- cityus';ivit":25 zipcicaszticifPhone# CZ° 1) '3%71- 351) EAsc-A-N- E0--,-x.---V-d <br />12-PrAcA-ro <br />Consultant/Sub Contractor Address --'57t•-`"'")°""c'''' Address °1 ') cz.-0- city 06,-, A UCI Phone# oqo <br />A-P rs'" P.- GIS Coordinates: X Township -A-s Al Range Section <br />WORK TO BE PERFORMED: <br />fl NEW WELL i BORING1 CPT <br /> --/ g <br />WELL # <br />*Other: \)441E'N'''-> Pelt_ t.-As)( <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />I] MONITORING fl HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? fl YES g NO WELL CASING DIA: AA - <br />fl EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS •,--) P TYPE OF CASING: I] STEEL I] PVC p OTHER: <br />fl VAPOR B MUD ROTARY DEPTH OF GROUT SEAL A TREMIE TYPE TO BE USED: 0 AUGERS 1:1 HOSE <br />0 AIR SPARGE 1) PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />'volt_ BORING I] HAND AUGER GROUT SPECIFICATIONS: is-2 .4 <br />0 OTHER: OOTHER APPROX. BORING DEPTH 5 [I BOLTED TRAFFIC BOX or 1] 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 <br />Print Name -3-1")"0 4"/•,-,--, V- Pii•e--k-,‘--'"<_ <br />Joaquin County <br />HYDROPUNCH, HAND-AUGER, OTHER*) <br />RING # 2 liv-60.."' <br />ce,-`431.out Specifications: .C)=A-rrA-A-7 <br />1:1 DESTRUCTION (choose type below) <br />D OVER-BORE <br />['PRESSURE GROUT <br />Sc _ <br />Date <br />DEPARTMENT DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /6? <br />ii ) <br /> 7-0 <br />WORK PLAN DATED: 2-7 —02.-- <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />/et-444-,4e. <br />61625‘ <br />7-- 24 <br />ACCOUNTING ONLY: AID# Ar"4.F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE -_ .INVOICE <br />350 1, 5 ..-- 'ci 7 .523 o 3,24, .57- I 2_— gut (3{9,-`? e?2_25- <br />C-57 I C -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encro—a-Ehnitrt-doc - 9/27/00 <br /> <br />144/st/