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Area <br />Final InspectionBy ,Date Date Date <br />Date <br />Date Issued Application Accepted <br />Grout Inspection By <br />Destruction Inspection By <br />WELL PERMIT APPLICATION FORM <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 />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct antior 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 JcaoLin County Public Health Services, Erw'rcnmental Health Division. <br />Assessor's <br />WELL Location /./f Air, 21714 Rd t Cross Street lefl'717/ feCe—City $-4.2c/eke, Zip Y.$-2.064 Parce147-/k) <br />PROPERTY Owner/04 Winberf- f-040/-er- Address/ 2/ -r; 72-e /4 City .54C ,e7642 Zip Y.5:30a h o n 0401) Y.63 V9F6' <br />C-57 ContractorMeykew/ Okd'/Acc9- Address2.0,80)C 336 City,610 V.'ciaL_Zip.7)/3"/Lic hone5/707),,?7X5114e)0 <br />Consultant / Sub Contractor/IA.540,1 Ce0-51iiiwiegr(Addressina eet SIVA- City Vece/AlLict4S-47,,r7Phone# (5464/ <br />Range GIS Coordinates: X , y /y Section . Township <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER') <br />1:1 SOIL BORING # <br />,WELL # <br />'Other: Grout Specifications: \.[\ <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />)(MONITORING 0 HOLLOW STEM <br /> <br />0 EXTRACTION D AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br /> <br />AIR SPARGE a PUSH POINT <br /> <br />0 SOIL BORING [] HAND AUGER <br />OTHER: flOTHER <br /> <br />CONSTRUCTION SPECIFICATIONS <br /> <br />DIA. OF BOREHOLE if a MULTIPLE CASINGS? 0 YES po WELL CASING DIA: .2 b 3 <br />CASING THICKNESS Ye 4 90 TYPE OF CASING: 0 STEEL ,PVC 0 OTHER: <br />DEPTH OF GROUT SEAL g/ TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br />GROUT SEAL PUMPED: ,'es U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') c <br />GROUT SPECIFICATiONS: /yec7 4 ceole.o` < 6eiveD07,*4.. <br />APPROX. BORING DEPTH POLTED TRAFFIC BOX or [I STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 4/0 ( if YES, list specifications here): <br />/fric4)5/ <br />fl DESTRUCTION (choose type below) 5---) <br />[] OVER-BORE <br />0 PRESSURE GROUT <br />*COMMENTS: <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 Ordinance o Rules and Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/Company <br /> <br />Print Name <br /> <br />;-c/ h•-e //G. // <br />DEPARTMENT USE ONLY <br /> <br />Date <br /> <br />SITE MAP IN UNIT IV FILE, ADDRqSS: <br /> <br />- <br />WORK PLAN DATED: <br />, <br />COMMENTS I CONDITIONS. <br />ACCOUNTING ONLY: AID4 FACI* (Tj S'R <br />..- <br />1o9..cp3e9'_3 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE <br />5.591,. ifilliie__ -, ' . _ 526h SR# 24e: 9 3 <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />9/27/00 <br /> <br />a. ED <br /> <br />ES:OT 000716T/OT