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*C.L THE UNIT IV INSPECT 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Title/Company 4> oP <br />Date ('-,-O2.. <br />m_Agta, it co <br />Print Name <br />Signed x <br />SITE MAP IN UNIT IV FILE ADDRESS <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Area <br />Date <br />ORK PLAN DATED <br />NT USE ONLY <br />Date Issued <br /> Final Inspection By Date <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 />SITE <br />MITIGATION <br />UNIT IV <br /> <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 °l ZSC, . 4.4.1 9i Cross Street 0000 Par% Pifit5 City he trrwco Zip 2-C22° Parcel# 6/ 7 -01 -0 34, <br />PROPERTY Owner 10ebsteet-7 Cik Sortcw • ro.u.Address ESC, We-41 PON>. AIA' City StercaAve-sit Zip q1'2? Phone# 9 lb -.383— or& 3>,,t " <br />C-57 Contractor aglanniaNZIMair Address 17-b- S. 0( S4 vi' zip ci C7 Lic# Phone# 70? S 7 41-- er(doo <br />C-211.tv <br />Consultant / Sub Contractor 1). Benmes. Re. Address 6 7 3 Grni ¼La1 Le) gi City Le) Lic# Phone# 1,29 - Veci - f/K <br />GIS Coordinates: X , Y , Township Range <br />WORK TO BE PERFORMED: <br />$1 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />*SOIL BORING # Me./ A AM0,5 <br />0 WELL # <br />"Other: GROUT SPECIFICATION <br />COMMENTS: <br />Section <br />I] DESTRUCTION (choose type below) <br />[:1 OVER-BORE <br />a PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE <br />MULTIPLE CASINGS? [] YES I] NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL I] PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: fl AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATION <br />APPROX. BORING DEPTH [] BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />TYPE OF WELL INSTALLATION TYPE <br />gMONITORING [] HOLLOW STEM <br />0 EXTRACTION [] AIR HAMMER/DRIVEN <br />0 VAPOR [] MUD ROTARY <br />1] AIR SPARGE K.PUSH POINT <br />111.SOIL BORING []HAND AUGER <br />0 OTHER: [] OTHER <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this <br />County Ordinances, State Laws, and Rul <br />plication and that the work will be done in accordance with San Joaquin <br />s and Regulations of the San Joaquin County. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' / BY, DATE PERMIT! r a INVOICE <br />-- J7)) 5o 9. DO li l'Ac\3 4(8 02. -; 003 0 -) <br />C-57 WC/WAIVE' :2 C-57 Letter vcif Authoriza on to permit <br />