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, Township GIS Coordinates: X , Y Range Section <br />E°10.1/414'Q .1v'e <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 /> Title/Company <br />Date <br />Print Name c- DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: 1 AID# A (^If <br />6711 e:g <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />32)3 (V?2-T / CO IN <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />Or - - 1 7 ,ENV1-R0i4MENTAL HEALTH DEPARTMENT (EHD) <br />.9 n <br />4 11/4 E. Weber, Third Floor, Stockton, CA., 95202 ulnA, <br />PER jilifv/E/Vi- (209) 468-3449 <br />i t/Setip, /1E447- r 1 L' <br />" U t 8 40N-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 />Assessor's <br />WELL Location20'51P ,1J€ 2 'y D r Cross Street Z7he 404A' 5 City 5-7—#- Zip `7c-Ze%-"Parcei# /03 -3/e -07 <br />PROPERTY Owner A 4'Q' G. e ef t) Address —0•7•4 t°2 City Zip Phone#02, -y,2 Y...20,0 g. <br />A a az, <br />C-57 Contractor Pill-6J Address,d 4y 9.7e' City Anore/ Zip 9lLic# Phone# 7.2a5i, 9' <br />Consultant! Sub Contractor Ce0 "44-r e ACw,/ Addresstqf571444smia ..., City ti0.04427Lic# ylar, Phone#P4? 474-"Gr..ZP, <br />fl NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, IlAND-AUGER, OTHER*) ,)'6ESTRUCTION (choose type below) WORK TO BE PERFORMED: <br />O SOIL BORING # U <br />0 WELL # <br />v:6)VER-BORE <br />RESSURE GROUT <br />tZ <br />CONSTRUCTION SPECIFICATIONS ...._,, <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />GROUT SEAL PUMPED: a Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: c <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE L.---- <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <br />COMMENTS: pi" .5 fa r _d 3)very--- <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />X-MONITORING 0 HOLLOW STEM <br /> <br />U EXTRACTION 0 AIR HAMMER/DRIVEN <br /> <br />fl VAPOR OMUD ROTARY <br /> <br />a AIR SPARGE 0 PUSH POINT <br /> <br />SOIL BORING U HAND AUGER <br /> <br />OTHER: a OTHER <br />*Other: Grout Specifications: G"/ cs- <br />3 2- Li .06y 1/41 <br />Signed x <br />SITE MAP IN UNIT IV FILE, ADDRESS: ab50 irLk-U-Gy Uttai <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />Date Final Inspection By Date <br />Date <br />zzit- Lop <br />Date Issued al ti07 Area qg <br />DATE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY PERM <br />chm <br />T# INVOICE <br />1/25/02 <br />SITE <br />MITIGATION <br />UNIT IV