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- <br />ORIGINAL ORIGINAL <br />0`k <br />3ROPERTY Owner <br />;-57 Contractor <br />;onsultant / Sub Contractor9Q, <br />3IS Coordinates: X <br />WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />UNIT IV <br />arty- Row <br />0 Fr tk.adx.3 <br />Section OA <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 />Vplication 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 r),,,Ionn,nt Title chanter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />NELL LocatIor /(.0.5 01-14-61--eige <br />Assessor's , <br />Street Ae(A1/14)City Lit.Vilibkeit Zip Parcel# <br />Address ikJiA , City LCIHItbb1 Zip1-115/0 Phone#.(q1( i6 <br />Address 32- <br />8.-//61 <br />cit lyV vi "lta Lic# Phone# <br />Address3017 i9erc ti,Ste.10Rity OA Lic# Phone#11dft1-0440 Fr\ <br />A , Township NIA Range Jji <br />,ORK TO BE PERFORMED: <br />9 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />\ <br />V 0 OIL BORIRG # <br />>f\WELL# 501h1-111131 CUlti. (-) <br />Other: Grout Specifications: <br />3°MMENTS:VVOrktell-Wrilefti ft+ ihsr o .12DC/H.P14-70 Poo <br />ATIONS <br />MULTIPLE CASINGS? 0 YES NQ WELL CASING DIA: 2)1 <br />0 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />TREMIE TYPE TO BE USED: U AUGERS i] HOSE <br />No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />IWO& <br />COMMENTS: <br />01.1A ff-c-fititerilyt)(14 5' -IT -Ktkrt-rti I CV' <br />NOTE: OFFSITE BORINGS JEQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />fl DESTRUCTION (choose type below) <br />1:1 OVER-BORE <br />El PRESSURE GROUT <br />"Yrt'S <br />rYP OF WELL INSTALL t ION TYPE CONSTRUCTION SPECIFIC <br /> <br />,MONITORING XHOLLOW STEM <br />O AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />fl PUSH POINT <br />0 HAND AUGER <br />0 OTHER <br />] EXTRACTION <br />] VAPOR <br />] AIR SPARGE <br />] SOIL BORING <br />] OTHER: <br />j1 iv! t- vto. Ic 3C9-x <br />BOLTED TRAFFIC BOX or U STOVE PIPE <br /> ( if YES list specifications here): <br />1/r. e1,11(1014-1 tApplVivvit -,C,14 10 12tIckA/ -)%61 <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL ) <br />GROUT SEAL PUMPED: Yes <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 4 <br />CONDUCTOR CASING PROPOSED? <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />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 />3igned x 44,t),0 Title/Company' (VJC t11 .1 (..612. i(1-ley-4o I) cm Cli <br />3rint Name Kr4\i fliiOrac Date 101 162(0V <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: &' (OD 6464--kieSi.e1, ece--1744-4.-ise (2-a& <br />NORK PLAN DATED: - 2,7 --e) 2— 140/0 o 3- 7-4 2_ At <br />Vplication Accepted By <br />3rout Inspection By Date <br />Dbvt..ci 0)„, )estruction Inspection By ate <br />ACCOUNTING ONLY: <br />---/ <br />AID# <br />i <br />iNt-,11 <br />PE CODES FEE INFO AMOUNT REMITTED ' CHECK # REC'D BY DATE P : ,• "--- ' R P • . T # INVOICE <br />3501 , &L&) <br /> ',,,-- ( - r —, , 5:3 1 5-1 I <br />. i _ „, i . sR# 003/ 620g ' _ <br />'2-57 WC .7-WAIVER C-57 Letter of Authorization to sign perm xnent-ciet <br />.10MMENTS / CONDITIONS <br />64 ?V Date Issued 0,- -102- , • <br />%.. <br />_ Area _ <br />Date —6) — Final Inspection By AI*/ Date —6) <br />se- 1"-o,