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Signed x <br />Print Name uvA 1 bllarl <br />DEPARTMENT USE ONLY <br />Title/Company"2-k-CA <br />Date / <br />WELL PERMIT APPLICATION AM <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 />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 Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location AA) (oo-c Cross Street Fre1on.4- 54tity 54-t)(44:41 Zip 9c-0L0 5 Parcel# <br />PROPERTY OwnerZnri,Vete. Eetie7i1y(oroketSkddress 651a(t6t Ave, -7473 y City _S-4.exi-1--,1,7 Zip (IS)-(37Phone&?) 95-7-4/25:)._ <br />C-57 Contractor LdPf-5-/-1-16Z.414+ Dt/i//' Address 13).:; 6 era IS) 0. 5re;frCity 411 C140 Zip c 5-7Y./Lic# 55VV?Phone#Q_:1/(7)6511" 7,2 774 <br />(orcto-)€i <br />Consultant / Sub Contractor49kvavitd ttv1ftiddress (-100-Cja luky City 5-1-0(„PfDr)Lic# EgOrt,PPhone# ) q67 -100 6 <br />SITE <br />MITIGATION <br />UNIT IV <br />GIS Coordinates: X Y , Township <br />WORK TO BE PERFORMED: <br />314NIEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />SOIL BORING # <br />VVELL # ukt ./VIL0S"1 .N114/6 Attr7 <br />*Other: <br />Range Section <br />RECENF:1 0-D,..STRUCTION (choose type below) <br />B OVER-BORE <br />fl PRESSURE GROUT JAN 1 6 20 01 <br />Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING I(HOLLOW STEM <br />B EXTRACTION 0 AIR HAMMER/DRIVEN <br />U VAPOR a MUD ROTARY <br />0 AIR SPARGE PUSH POINT <br />SOIL BORING II HAND AUGER <br />fl OTHER: fl OTHER <br />*COMMENTS: <br />Fi\IVIRANMI--N [ HPAII H <br />PERMIT/SERVICES <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 5'' MULTIPLE CASINGS? a YES Io WELL CASING DIA: 67( <br />CASING THICKNESS 56-whit' V() TYPE OF CASING: a STEEL A'PVC 0 OTHER: <br />DEPTH OF GROUT SEAL (2 irL) v TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />GROUT SEAL PUMPED: a Yes ro (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: (ikt ii, 64c c< 40 c,qllons <br />APPROX. BORING DEPTH 5$' OLTED TRAFFIC BOX or B STOVE PIPE .S". <br />CONDUCTOR CASING PROPOSED? A ( if YES, list specifications here): <br />-N <br /> <br />'fs-r1 <br /> <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 /> <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County 0 'nances, Ruls i5IRegulations, and all applicable California State Laws. <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: L\, iOikiusq--- ,c21-c:19 0 <br />Application Accepted By [eV 1--m..vtrr _. A.---, Date Issued 1 1 1 7- )° .1 Area <br />Grout Inspection By k.-\ -' Vv. (,-1 Date 2-- \ b IC I Final Inspection By 04iez,--4. (cl (<5 I Date <br />Destruction Inspection By <br />• <br />_ <br />ACCOUNTING ONLY: AID# <br />_ FAC:# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUE INVOICE <br />3 5-0I 1 <69,00 19 S-611 14 I ill-/((‘ SR# ODA S-0.-9- <br />. . rt in -tit-1n <br />-WAIVER C-57 Letter of Authorization to sign perm t C-57 <br /> <br />WC