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ORIGINAL <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 />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 Environmental Health Department. <br />04 4 41,i44C Ave.Assessor's <br />WELL Location 114 (0 S9 N. MoRN Tan <br />, . <br />Cross Street -140,40Tc,, RA ADCity Zip 152 y.5 Parcel# <br />(341K i#E5 <br />k Zip95Z-51 Phone05 i 147 133a woopilitio‘ PROPERTY Owner 1. 2.0•1; rte Pirm,.y3p Address P.o.a.y tytt City <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) B DESTRUCTION (choose type below) <br />U SOIL BORING # a OVER-BORE <br />"aVELL# OS-I )1140W14,Muu-fc 1 AlYti•fie t ti1Va •ri, Mu., 'Ili 0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />A <br />....) if <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE "8 " MULTIPLE CASINGS? 0 YES A NO WELL CASING DIA: Z. <br />a EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS SU49:1%14 TYPE OF CASING: a STEEL )g'N/C B OTHER: <br />O VAPOR a MUD ROTARY DEPTH OF GROUT SEALS 0 Ftt 1-b5CPTREMIE TYPE TO BE USE: IcAUGERS a HOSE <br />0 AIR SPARGE l] PUSH POINT GROUT SEAL PUMPED: Xes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />, a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: peF171_,,o I yP. --IZ <br />OTHER: csIZAr._ 0 OTHER APPROX. BORING DEPTH 7o FtE..-1- ic3OLTED TRAFFIC BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED? I•1 • (if YES, list specifications here): <br />*COMMENTS: SEE- <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 Ord*nances, Rules and Regulations, and all applicable California State Laws. <br /> Title/Company Pp..5ecr Signed x <br />• <br />2_ <br />SITE <br />MITIGATION <br />UNIT IV <br />Rbc,i4Nis <br />C-57 Contractor CA SCA OE At.. Address St, $)C c t City c80.41tA4v°A Zip 95 7Y4Lic# 71 751 ° Phone0/1) 6/5 / /6 / <br />Clt0 <br />Consultant/Sub Contractor Ach, A *A Is/dress MI 5A .1 R.) . City S Tot C'Ion Lic# 68 ZZ7 Phone# (20) 96 7 / 0 ir <br />GIS Coordinates: X , Y , Township Range Section <br />RuMce. - <br />oq8PRovtin (A) oRK NA/ ch3.-re6 09 MAY zc.o7— <br />Print Name ..-77;C:rht 7 LL Date C1 9- 16 <br />DEPARTMENT USE USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 544/ a/ . <br />WORK PLAN DATED: 4:6144 ---v74 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />97Date Final Inspection By Date •-•6 <br />Date Issued 9—te- 0 2_ Area e6P-5/ <br />Date <br />a4)-e <br />ACCOUNTING ONLY: AID# C A r•-ht <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE IT / SERVICE REQ T INVOICE <br />350i WO 411/ /73z-)/ 64-tt "2 <br />(SR # 003/L 3 ? <br />C-57 ./". WC -WAIVER C-57 Letter of Authorization to sign permi <br /> <br />1/25/02 <br />