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EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />OIL BORING # <br />U WELL # <br />WORK TO BE PERFOR <br />2-1S1EW WELL / BORI <br />"Other: <br />COMMENTS <br />rout Specifi bon: <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 />WELL LocatIot. ImM5_ . „A4C7C <br /> <br />W Street <br />011741NA' j - <br /> City-S:4°C °---4-7Wq.S7 s. Zip - Parcel# e)-' Assessor's <br />PROPERTY Owner Address ity5 -'42 A ZiPS21)5—Ptione#(11,V3) <br />C-57 ContractorG (E•>6'0 tk\ VIZA, . Address/50 ND-4p42,..- RS__ CItYS7 yj iP ,3Lic#"7pho it5 313 <br />PhonetM //6 2/0(k <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV Per 0)5 <br />Licior <br />P‘e >ix • Consultant / Sub Cntr A 6 -C— AddressYS? city5 r-4,1Lic# <br />GIS Coordinates: X , Y , Township Section <br />0 DESTRUCTION (choose type below) k..11 <br />0 OVER-BORE <br />PRESSURE GROUT k.p, <br />Range <br />TYPE OF WELL <br />I] MONITORING <br />I] EXTRACTION <br />D VAPOR <br />O AIR SPARGE / <br />,osolL BORING <br />U OTHER: <br />'COMMENTS: <br />INSTALLAIION TYPE <br />U HOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />MUD ROTARY <br />Ozone IfitisH POINT <br />U HAND AUGER <br />U OTHER <br />/-) <br />_(.1 I 6W—y kvji <br />CONSTRUCTION S ECIFICATIONS/ <br />DIA. OF BOREHOLE 1. ivirafTIPt.E CASINGS?'" MULTI-LEVEL? fl WELL CASING DIA: <br />CASING THICKNESS A/A- TYPE OF CASING: U STEEL El PVC [I OTHER: <br />DEPTH OF GROUT SEAL En TREMIE TYPE TO BE USED: I] AUGERS a HOSE <br />GROUT SEAL PUMPED: "Fifes a No ( OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: POC-1 /1"pl <br />APPROX. BORING DEPTH P;e0 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR ASING PROPOSED? ( if YES, list specifications here): <br />C4,13 (QM / <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Aok— <br /> <br />qr• Title/Company — ) Oej C sr <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 FILiA/1) a)/ <br /> <br />,s4( ze4 <br />WORK PLAN DATED: le& 1+.-/' <br />Application Accepted By Date Issued C <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By 3 Date <br />COMMENTS / CONDITIONS: /C/1725 67)1_ Za-X70-4-11-0-5 / Aoci-o-e <br />ACCOUNTING ONLY: <br />o <br />AID# ' <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # R C'D BY DATE P: ,, - • . 7 # INVOICE <br />f)17 45) ii°j2- r7617 ? 1 <br />C-57 WC WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />doc <br />7571-2- <br /> <br />8/29/02 <br /> <br />Area <br />Date