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Date Issued Application Accepted By Area <br />ate Date 1"- -0(-) Final Inspection By <br />Date <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />WELL PERMIT APPLICATION FORM I a- <br />• <br />L L VL. <br />, <br />IGATION ENVIRONMENTAL HEALTH DEPARTMENT (EH <br />304 E. Weber, Third Floor, Stockton, CA., 952A 01 2004 <br />UNIT IV <br />(209) 468-3449 <br />SAN JOAQUIN COUNTY <br />L:NViRuNMENT HEALTH C NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE fSg44FAIT/C yr F <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Ktridde in compliance with San <br />Joaquin County Developmept Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL LocationoHir) /10:),\ :-.1)-tr-9....22-1. Cross Street I 1.1t,e.r•-1 .)-r. City •S-Itc- k-ecvl Zip ,5 // <br />/A <br />ParceI# <br />PROPERTY <br />Owner Lie:. Address'/ . N. bt,T-J0 Ci 44c4c1 p c/52.02-- Phone#(7-41") B.4-133 4ict <br />C-57 Contractor(' cA. Address/So WCV..tjf_ ;?,(›k City Mat-4:AQ.Zip.74r5S:i Lic# €.564(.-; Phone# 92.5 - a 13 - S'iSca <br />Consultant / Sub Cntr Address Lic#2-c. Phone# ct5 -`11f5c. <br />GIS Coordinates: X <br /> <br />, Y , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />fi NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTH'"t"') <br />SOIL BORING # .513- 2_c - a2- tiLm-c-45-"•- <br />LI WELL # <br />O -Other <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />U OVER-BORE. DIAMETER <br />I) PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE fl MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS AVA TYPE OF CASING: J STEEL PVC a OTHER: <br />EPTH OF GROUT SEAL ! 5 TREMIE TYPE TO BE USED: p AUGERS 11 HOSE <br />ROUT SEAL PUMPED: II. Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS 1:::C.r-4 (4.-101 <br />APPROX. BORING DEPTH /.,5c J BOLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED A (if YES, list specifications in comment section) <br />COMMENTS: --- <br /> _ <br />OFFSITE BaRINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 Tale/company r- .:15-/C1 <br />Print Name Q'Ic=1. fv-1 ; /-% Date (C2 4f <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: •;9(fi?6 767'44-• <br />WORK PLAN DATED: <br />MONITORING p HOLLOW STEM <br />p EXTRACTION <br />a VAPOR <br />O AIR SPARGE/ OZONE <br />El SOIL BORING <br />o OTHER: <br />a AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />III PUSH POINT (GP <br />p HAND AUGER <br />a OTHER <br />5rz- / <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQTJEItit-, INVOICE <br />.3,6&' 1 S-!) '11?' *3,5 ,t,-- 6- 1 (--ER# do3gY2-2_ i ,- <br />C-57 WC V -WAIVER C-57 Letter of Authorization to sign permit Encroachmeni doEiiiV . 9/30/02 <br />ke 3ay <br />1 /4_1<pi ?-/s V <br />