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0 DESTRUCTION (choose type below) <br />a OVER-BORE <br />---r <br />' 0 PRESSURE GROUT <br />Le Y <br />/ <br />:% E.C___ <br />a i) 51 Area <br />Date -49° <br /> <br />INVOICE <br />F A r. <br />REC'D BY DATE <br />8-15 <br />Loo etZRAC DAV—ED L(47///0 2, <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 />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 />4104 <br />Assessor's <br />Poross Street LAP4.1 E PE city 6reCKTII kJ/Zip cic (eyarcel# <br />WELL Location <br />PROPERTY Owner 1-41Oi..iU4FY Address 436 \M66715 AV city .-Torfrieik) zi44,-zephorie# %6--4q6--c <br />C-57 Contractor 5-11E4e u Address 23i,5- /44/V4m City5rer../Zro0i65-7C5tic#ZZ‘4'hone# <br />Consultant / Sub Contractor ver—n-i LL EtilArr.r-46r-e-ss (Z.Trqg Worn a6;16-0- 10D( 'Jot 167752. Phone# 36.E. -13R, I <br />GIS Coordinates: X , Y <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />C)N1 <br />, Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />U NEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />SOIL BORING # <br />U WELL # —U-ffT.L.. ( <br />Grout Specifications: 'Other: <br />COMMENTS: <br />TYPE OF WELL INST31,,LATION TYPE <br />0 MONITORING 04OLL0W STEM <br />VXTRACTION [] AIR HAMMER/DRIVEN <br />VAPOR OMUD ROTARY <br />0 AIR SPARGE 1:1 PUSH POINT <br />(I SOIL BORING fl HAND AUGER <br />U OTHER: 0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE (5 14 MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: 6. 4 f <br />q 5 <br />CASING THICKNESS 5C.1-( 4o TYPE OF CASING: 0 STEEL gr4116 a OTHER: --, <br />DVDTH OF GROUT SEAL 'W' TREMIE TYPE TO BE USED: frAlGERS trrIOSE D . <br />GROUT SEAL PUMPED: D Yes 0 No (NOTE:71 JUMUM FREE-FALL DEPTH IS 30') <br />rkf <br />'Z <br />GROUT SPECIFICATIONS: c-ter 0 6-E-1-__ <br />APPROX. BORING DEPTH 6 ' 1,86CIED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NI-) c if YES, list specifications here): <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 t ' application and that the work will be done in accordance with San Joaquin <br />County 0 nces d Reg a ons, and all applicable California State Laws. <br />k Title/Company (ADVE/Z_ grqr--/ Fa(tbscogal, <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By <br /> Date <br />Signed x <br />Print Name 5/2/1/4) -.10,754, <br />DEPARTMENT USE ONLY <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: 300 5 - Cat-60 <br />WORK PLAN DATED: <br />Date Issued <br />Final Inspection By <br />COMMENTS CONDITIONS <br />ACCOUNTING ONLY: AID# <br />PE CODES AMOUNT REMITTED CHECK # <br />ere( <br />-WAIVER C-57 Letter of Authorization to sign perm <br />PERM5,02101telE=R64114§; # <br />Encroachment doc <br />FEE INFO <br />s2'3 9/27/00 <br />C-57