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SITE <br />MITIGATION <br />UNIT IV <br />e Area Date Issued <br />Date <br />Date <br />o6d9V <br />Final Inspection B Date/V .2)7 -0 2- <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS/CONDITIONS: <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />02 jun ENViilohMENTAL 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 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 />r . Assessor's <br />City t< Ore r zip <br />, <br />9E367 Parcel# -2_ 1- OTO -012_ <br />PROPERTY <br />Owner LA) r‘‘‘I Prii -.IL)°, I.:1 Address 667 CYC:arcet *C)City -SciA r-C4A cfitct-, Zip `1410i Phone* IS) 4°- 2 c-)L17 <br />C-57 Contractor \i c\'" r:111 AddressP,O, ge)( 4 16 Ci delOA Zip tig6141 Lic# -12004 Phone# (411c)771-400 <br />°) ,- ( Consultant / Sub ContractorS Address '3Ci1 K-'t 6' re Pcz‘SteICity 610:3\ r-CAirvel Lic# 6102- Phone# (clit)Vti--0 9 00 <br />GIS Coordinates: X , Y ,Township S t“-`04\ Range 9 E. a Section 2_4 <br /> <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />[] SOIL BORING If [j OVER-BORE <br />,KWELL # \/-7, V-%, v -9, v -101 1)-ti, \i L2. V -13 0 PRESSURE GROUT <br />*Other: ,\re II 4:6S S-1 ihre,,cp. e- -.), ZO Grout Specifications: <br />COMMENTS: <br />- I I <br />S - wel ?/q d ,e. <br />DIA. OF BOREHOLE MULTIPLE CASINGS? [] YES )(NO WELL CASING DIA: <br />CASING THICKNESS sct1/4 4L+suliGTYPE OF CASING: [] STEEL XPVC [] OTHER: <br />DEPTH OF GROUT SEAL Cif TREMIE TYPE TO BE USED: 141 AUGERS ;[(1'1-10SE <br />q.A.ver-wetts. <br />GROUT SEAL PUMPED: *Yes [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS. <br />v-Vvey% <br />APPROX. BORING DEPTH 10' <br />CONDUCTOR CASING PROPOSED? No ( 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 t Title/Company - b..CR 4r At 1--%Ctkci <br />Print Name @I-ICA VN C.-61 r-e S t-a14 G eclai ic 1-- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 23567 47 5- /241 <br />WORK PLAN DATED: j <br />WELL Location23St°1 T----e R. a Cross Street <br />TYPE OF WELL INSTALLATION TYPE <br />[] MONITORING ii:HOLLOW STEM <br />[] EXTRACTION [] AIR HAMMER/DRIVEN <br />XVA TR [] MUD ROTARY <br />irta SPARGE [] PUSH POINT <br />[] SOIL BORING [] HAND AUGER <br />[] OTHER: [J OTHER <br />CONSTRUCTION SPECIFICATIONS <br />XBOLTED TRAFFIC BOX or [] STOVE PIPE <br /> <br />Date <br /> <br />ACCOUNTING ONLY: AID# f1r`4+ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE p cgravir,F FIFPUEST # INVOICE <br />of Weal Ft?: ,--24?1/ eldE (/ SRit Oti3W) <br />/C-57 Letter of Authorization to sign permit 7.-Ertmaachmeat-eiat*4 9/27/00 C-57 / WC 7-WAIVER