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6 Area Date Issued <br />Date <br />Date <br />0. <br />Final Inspection !LE <br />, <br />TED Date 617-0 3 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <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 />ORIGINAL <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />ON 40-J5 <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 />,., Ass <br />e <br />e's <br />WELL Location PCirb 14- Cross Street City Si-ockto A. Zip 95-z°, Parcl# <br />ssor <br />14-5-030 -CD <br />PROPERTY Owner 17ortO ockboll Address F. a (Sox aogcl City katc,C1c1:73K Zip95 -° Phone#1Dc1-914-4,- °-224) <br />C-57 Contractor Spec-Fruni Enloroitmaddress .2365 Ms wa" Dr cityStockivrt zip15-105Lic# Phonek2oq-4,65-.9 I <br />Consultant/Sub Cntr G-eom ectr i Consaliuts Address .1444 a-in S-ie -/.15 City Fres no !Jot 6838 65 Phone# 559=264,1535 <br />GIS Coordinates: X , Y , Township I1\) Range 6 C.- Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />[] SOIL BORING # <br />gWELL # 3 -ED 5 <br />*Other: Grout Specifications: <br />COMMENTS <br />fl DESTRUCTION (choose type below) <br />fl OVER-BORE <br />fl PRESSURE GROUT r\e04 - PAefrv± <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />((MONITORING gHOLLOW STEM <br /> <br />EXTRACTION 0 AIR HAMMER/DRIVEN <br /> <br />VAPOR [] MUD ROTARY <br /> <br />U AIR SPARGE [] PUSH POINT <br /> <br />SOIL BORING [] HAND AUGER <br /> <br />El OTHER: 0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS ga-P <br />DIA. OF BOREHOLE 10 e( MULTIPLE CASINGS? fl YES 1/4.JO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE To <br />GROUT SEAL PUMPED: g Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: neat - men-L <br />APPROX. BORING DEPTH m AOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 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 .17/1/1A/k. 0.0 Title/Company StAif vi1 neer/d" 10p+ / Geo r"14r;)C <br />Print Name IA - jeo <br /> <br />Date <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />4a/el /t4/r, ij(tod -02- <br /> <br />ACCOUNTING ONLY: AID# <br />FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE ST INVOICE <br />( itta) <br />.--- <br />C-57 V WC -WAIVER C-57 Letter of Authorization to sign p rm 1/25/02