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Date Issued <br />Final Inspection By Lk:::"AA,.c.,-,„ Date 6/2-S102 <br />I zolo Area <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 />WELL Location ‘/a%' /4744/K 97 Cross Street %Nit 44! City creWZ-Ir/1/ Zip 53-e--e/Parcel* <br />Assessor's <br />PROPERTY Owner SiC/rin4AiriG 441iettUddress /7.0..avx City /4/110'1- Zip 'WAPhone* 7757-24.1-11/7 <br />C-57 Contractor -,096e-Fh2.- _A-11-LeAl, Address 36.32- egyee-ah4rorZip-Lic#7/75-78 Phone* <br />30'7 Krz- e.-e XI) Afric//v <br />Consultant / Sub Contractor,5_-eV,--- Address -al-co City Cagia4t- !Jolt Phone# AC--ek/-c7Yer <br />GIS Coordinates: X <br /> <br />, Y ,Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />X1EW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING If [l OVER-BORE <br />5(WELL # 7.24-10 e.4.1-1.--,1_-_ n PRESSURE GROUT <br />*Other: Grout Specifications: <br />DM. W - ( COMMENTS: b Yvt,t0 <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />)(MONITORING 'HOLLOW STEM <br /> <br />EXTRACTION [] IR HAMMER/DRIVEN <br />[] VAPOR [] MUD ROTARY <br />[] AIR SPARGE [] PUSH POINT <br />fl SOIL BORING [] HAND AUGER <br />El OTHER: [] OTHER <br />77.1/D <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g# MULTIPLE CASINGS? [] YES )NO WELL CASING DIA: <br />CASING THICKNESS THICKNESS 5e# ‘42 TYPE OF CASING: [] STEEL )(PVC [] OTHER: <br />DEPTH OF GROUT SEAL 70 TREMIE TYPE TO BE USED: *AUGERS [] HOSE <br />GROUT SEAL PUMPED: AYes [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 1/t/.4"r7 <br />APPROX. BORING DEPTH /C90 1,,/ ,BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /1/0 (if YES, list specifications here): <br />77' /Ce, c-e-ei--.-7-eo/ -7co *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, ules and R gulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/Company V#e <br />Date -5 ::-Zfr:-"C <br /> <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 2_( 1,0/ <br /> <br />(,) 00 iv •NAG, c-15 <br /> <br />Application Accepted By <br />Grout Inspection By U>s,\Anikpt-A.__ Date 6tz--k[OZ_ <br />Destruction Inspection By Date <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID* CAr`4 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />35-0 sci.co Sz-CagS /Ac 6 /2÷Z SMC03 0)% Li 3 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />9/27/00 <br />