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SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: <br />RESS: <br />Date Issued Area <br />Final Inspection By Date Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />1/25/ hmentdo <br />WELL PERMIT APPLICATION FORM <br />APR 20 2004 SAN JOAQUIN COUNTY <br />HEALTH ENVIRONNILI <br /> <br /> <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />\IT <br />PERMIT/SERVICES <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. Assessor's <br />I„. Cross Street 1\1 - " ci City t ' A Zip C 3 r Parcel# 'Ae-. <br />1, <br />Address ILI `) f\ C,- <br />;_),City zip 91 S 7Lic# 7 6 S-121Phone# /(76 <br />Address 111 trA k o City r t' ic# phone# = <br /> <br />Range Section <br />11(DESTRUCTION (choose type below) \.A <br />B OVER-BORE <br />%PRESSURE GROUT (Th <br />SITE <br />MITIGATION <br />UNIT IV <br />) WELL Location 1) <br />PROPERTY Owner .±L <br />C-57 Contractor V Address <br />Zip 1-17 Phone# <br />Consultant ! Sub Contractor <br />GIS Coordinates: X \A/ 1 )-1' / I " = <br />WORK TO BE PERFORMED: <br />fl NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />a WELL # <br />, Township <br />Grout Specifications: <br />0 AIR HAMMER/DRIVEN <br />*Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />gMONITORING 0 HOLLOW STEM <br />0 EXTRACTION <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING B HAND AUGER <br />0 OTHER: 0 OTHER <br />rv, <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES 0 NO WELL CASING <br />CASING THICKNESS TYPE OF/CASING: 0 STEEL PVC OTHER. <br />DEPTH OF GROUT SEAL TAEMIE TYPE TO BE USED: [I AUGERS HOSE <br />GROUT SEAL PUMPED: fl Yes <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH .C" B BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />*COMMENTS: c' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />I hereby certify that I have <br />County Ordinances, Rules <br />Signed x <br />1 f` <br />Print Name "i • <br />, <br />), <br />CALL THE <br /> THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />prepared this application and that the work will be done in accordance with San Joaquin <br />and Regulations, and all applicable California State Laws. <br />_ Title/Company 1,1 <br />Date <br />DEPARTMENT USE ONLY