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WORK PLAN DATED: tY7 Taivveze .iii <br />Application Accepted By <br />Grout Inspection By Date <br />Date Issued <br />Final Inspection By Z-4- Date <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. M(1) <br />WELL Location 5-3 Tryi Cross Street Cf-aliribia a City-T(7 Zip qiI7C IPTarcel# 437 <br />-3Assep.spr's <br />PROPERTY Owner Owner Yr Address ,;((6 I) 1-054 2- aty 1-01C/ Zipqg:/- C_Phone# <3 35 - 6 5.71 <br />C-57 Contractor LS CC 412 Pr fii;17 Address 3 OThec Cr city Aan (.IAO Zip1C741 Lic#1 I 757O Phone#0/ 16 ) <br />Consultant / Sub Contractor /464E-= Address •§7.31nee,) City HZ:T- Lic#6g0/10)? Phone# V6 7-/066 <br />GIS Coordinates: X Y <br />RK TO BE PERFORMED: <br />KNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />L SOIL BORING # <br />AV ELL/! ELu 1 4- 01,t)1 <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING .);(HOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />DIA. OF BOREHOLE 51I // 5- li MULTIPLE CASINGS? a YES 0 WELL CASING DIA: <br />EXTRACTION CASING THICKNESS SCA 110 TYPE OF CASING. a STEEL XfK/C a OTHER: <br />U VAPOR 3 MUD ROTARY DEPTH OF GROUT SEAL Q' 1952 TREMIE TYPE TO BE USED: R,AUGERS a HOSE <br />U AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes o (NOTE: DWIMUM FREE-FALL DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: Fe(-VI Gnoii re 4- e it <br />U OTHER: a OTHER APPROX BORING DEPTH .-0' a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /111) ( if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> <br />, Township <br /> <br />Range Section <br /> <br />U DESTRUCTION (choose type below) <br />U OVER-BORE <br />U PRESSURE GROUT <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 Re lations, apa 4 applicable California State Laws. <br />Signed x <br />Print Name er,gy, <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Destruction Inspection By Date <br /> <br />COMMENTS / CONDITIONS: <br />54a* e'())42/5+/A Title/Company <br />Date 6/c4 <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AID# <br />V <br />_ <br />FAC# CS R40030.2-/Pr <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE INVOICE PERMIT! SERVICE REQUEST # <br />lar S (7 Z.T5.- <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Auth iza n to sign permit Encroachment doc 1/25/02