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Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: 7395 #" 66 56 <br />Date Issued <br />21Final Inspection By <br />Date <br />2 --mu) <br />• <br /> <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />Off cos <br /> <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />Application is hereby made to <br />Development Title, rm:•-•-•-- " ^ <br />ddress <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-BORE <br />'SWELL # AA v 4- 1 7_, <br />Grout Specifications: <br />0 PRESSURE GROUT <br />*Other: fications: PrJ r1.0,D /yille— -I T-- <br />COMMENTS: SC^. E AfprD ‘A. QP,K, Plc,-.. LI-1-z° 1 5 Fi 13 Pvecti i 'Z. 0 0 1.-- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 EXTRACTION U AIR HAMMER/DRIVEN <br />MONITORING 'HOLLOW STEM <br />CASING THICKNESSy.viQ TYPE OF CASING: U STEEL XVC 0 OTHER: <br />DIA. OF BOREHOLE 3' MULTIPLE CASINGS? 0 YES X10 WELL CASING DIA: 2 <br />DEPTH OF GROUT SEAL Z. TREMIE TYPE TO BE USED: AAUGERS 0 HOSE 0 VAPOR 0 MUD ROTARY <br />GROUT SEAL PUMPED: U Yes po (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 0 AIR SPARGE 0 PUSH POINT <br />GROUT SPECIFICATIONS: 0 SOIL BORING 0 HAND AUGER <br />APPROX. BORING DEPTH 95 FT 135(-- jcBOLTED TRAFFIC BOX or U STOVE PIPE 0 OTHER: 1-1 OTHER <br />IDUCTOR CASING PROPOSED? fr ( if YES, list specifications here): <br />*COMMENTS: V4.- 4 1 Ei4-45/ <br />C <br />5/.4d sp-y-e <br />/2-- at sum, 44- e <br />NOTE: OFFSITE BORINGS R1 QUIRE 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 County Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />I Signed x Title/Company Ge-0)09r7 <br />5/z v <br />( <br />WELL Location <br />PROPERTY Owner C..;1 F- s <br />C-57 Contractor' <br />Consultant Consultant / Sub Contractor A, G <br />GIS Coordinates: X <br />aquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br />+h. RtandarrIS of San Joaquin Cos..r)ttly0A7nvirRnpmental Health Department. 5 4. fri <br />Assessor's <br />Address 111 5 Al. EL Oc iZ AP <br />City STT:Toe-, Zip 5 2'"zi Pahrocenel# 9/4, if5er <br />, zip (15.Z v 2.phone#(24()) 72: Fr5 <br />pffZific <br />Cross Streetfhipx,- ' r <br />ii <br /> <br />.&ATX Z7')/ <br /> srp City 5 i„ e <br />Ci <br />Address 37 519 RD City-57 .11("r-Lic# 125 027Phone# tt:16)^ Y6 / 4,1 3 -7 <br />L r- <br />, Township c Range Section <br />11'm c 1/ELLA"-, Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: WO, /9 <br />WORK PLAN DATED: — - <br />Print Name <br />I. <br /> <br />- , <br />ACCOUNTING ONLY: AID# FAC# 11 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P - , - • r • • - T # INVOICE <br />o 1 t4Add Ect AoThl CIA-A. 7 <br />-. i, sRit 0e2 0,9 <br />C-57 <br /> WC -WAIVER C-57 Letter of Authorization to sign pe mi En ent doc /25/02