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r. Addres <br />, . <br />C-57 Contractor <br />Consultant / Sub Contractor A G <br />Print Name T/',/v) . vq..//tf-- <br />Signed x <br />z Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date Issued <br />Date Final Inspection By <br />Date <br />eb rft <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA, 95202 <br />OIl (209) 468-3449 <br /> <br />WELL Location <br />rsrt <br />, Y <br />WORK TO BE PERFORMED: <br />)ikIEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") a DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-BORE <br />AWELL # A/W -, 1 0 PRESSURE GROUT <br />*Other: Grout Secifications: P or 7 )‘; , 0 T-y, pE IL <br />517=E Allor) w mic al; i.L.4(4) ic FZ8tvc ' :- -4 2 - % c, '2— I <br />'MONITORING 'HOLLOW STEM DIA. OF BOREHOLE a it MULTIPLE CASINGS? a YES )(NO WELL CASING DIA: 4-- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS y q TYPE OF CASING: 0 STEEL Al-PVC a OTHER: <br />ey / / <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Zo Fr 8 5G- TREMIE TYPE TO BE USEb: XAUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />(:1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: pc4,006,01 Ty F- -7:--- <br />de_. ,t6. 6.5.._ CO DUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />0 OTHER: fl OTHER APPROX. BORING DEPTH (IS F7-656-p(BOLTED TRAFFIC BOX or I] STOVE PIPE <br />*COMMENTS: <br />it <br />,e-1/0"C. 7- Z —10 td <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 County Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />Title/Company <br />DEPARTMENT USE ONLY <br />GIS Coordinates: X <br />Application is hereby made to S <br />Development Titl- <br />F S-rat. 'Aci&ess 395 IV, jL iD6f4PQ "City 5Tec...Kror. Zit:0 52 0 2— Phone#0- 0 95 - <br />ik5 R aSi inlq AN_ <br />PROPERTY Owner C .7\1 o <br />I,- Cross Street El/41/4.ic,ic Avt City r -10.-,r-1 zip 951°7 Parcel# <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />n Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br />' " of San Joaquin County Environmental Health Department. <br />g IV& LAr4E Assessor's <br />41,173p 94 <br />g <br />gcz#5-r <br />AddressS 7 sdA v4 PP- City STGr..f(ror‘Lic# aoto Phone#V '1951)7 /O4 b <br /> , Township it3N/ Range -E- Section 5 <br />SITE <br />MITIGATION <br />UNIT IV <br />COMMENTS: <br />PROSE CT CCo/0)/5-, /i9 ..a <br />Date 0 STZ ,o 2- <br />SITE MAP IN UNIT IV FILE, ADDRESS: 0195 4C-4,<- a.,14-4-1.-71 <br />WORK PLAN DATED: 2 -/5 -O 2-- <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE SERVICE RE INVOICE <br />S5o 1 7/4",p, P 1 ' I ben- a4A z-V-, R# 00 ,t)Os? <br />C-57 <br />WC -WAIVER C-57 Letter of Authorization to sign permit /25/02