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*DESTRUCTION (choose type below) <br />)tOVER-BORE <br />a P, <br />Grout Specifications: PAQ-74fik0 rye( -77 77 <br />RUSURE GROUT <br /> <br />WORK TO BE PERFORMED: <br />0 NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # <br />"Other: <br />COMMENTS Kw-Aiodyv v-t) - <br /> <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 />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 Environmental Health Department. <br />WELL Locationql 1%1, 01-kt .&teiw Cross Street f-A1401.7-- City 7krai Zip fS-20 P <br />Aasrssso Assessor's ceel tt 1 <br />2't - Z. <br />PROPERTY Owner el Ty of ...<10euled row Address36- A I. a 00e4ht City542X/4.771A-/ zip?...rell 2 Phone# 937 - 87// <br />C-57 Contractor M 761-4:Gt.. PC4(.../il4- Address531A (--'A77 Avr. City Zip Lic# 6 / '14/7 Phone#(*6-)131 <br />Consultant / Sub Cntr A 4E. Address k' 37 .91'/14-t) ge) citySrizerifiv Licttii-6227 Phone# 4/6 7-l'") 6)6 <br />GIS Coordinates: X ,Y Township Range <br /> <br />Section <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? fl WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL ['PVC POTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ['AUGERS [I HOSE <br />GROUT SEAL PUMPED: U Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list spe9ificatio4here): <br />TYPE OF WELL INSTALLATION TYPE <br />fl MONITORING <br />0 HOLLOW STEM <br />[I EXTRACTION fl AIR HAMMER/DRIVEN <br />0 VAPOR a MUD ROTARY <br />0 AIR SPARGE / Ozone fl PUSH POINT <br />0 SOIL BORING fl HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: <br />/ <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 Ordinavls, le nd gulations, and all applicable California State Laws. <br />Signed x Title/CompanyA .›.7A1r ALIAticigt) V <br />Print Name (J-ncp,/ <br /> <br />Date /072YO 2_ <br /> <br />DEPARTMENT USE ONLY <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />LCI(AY--1-j Date Issued k 20o? Area <br />Date 10 77citr- Cinal Inspection By Date <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # FtEC'D BY DATE PERMIT / SERVIC EST # INVOICE <br />.._ l_ • <br />/ <br />, (.-.716:)0T ' 1 ( <br />C-57 WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization -to sign permit ----Ericroach-trretrrrx <br /> <br />8/29/02 <br />