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WC -WAIVER C-57 <br />WELPPERMIT APPLICATION FIRM <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 Sanaquin County Public Health Services, Environmental Health Division. Iv) titc City skceim zip qszas pAa smseeir rs <br />WELL Location .g032 FAST alAP.A433a Cross Street ..(, <br />PROPERTY OwnerVaa--/ Cate ., Address 3()%25T-6441.\41 4City Sit-&-6ts) Zipq-Zier-Phone# 4'2 '\J1 <br />ddressC150 -444e sek CityltikAkY4P3Lic#465/16Phone# t'S- sia ";7-374) <br />Consultant / Sub Contractor A .6 ,C-- Address R,?-1 5 (A__4Gef), City cketA/Pc# Pho& q' 107 tbA: <br />GIS Coordinates: X , Y , Township Range <br /> <br />Section <br /> <br />W WELL / BORINQFT OPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />U SOIL BORING # <br />WELL # <br />*Other: Grout Specifications: <br />COMMENTS: <br />SITE <br />MITIGATION <br />UNIT IV <br />C-57 Contracto <br />WORK-TO BE PERFORM fl DESTRUCTION (choose type below) <br />U OVER-BORE <br />U PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />a MONITORING fl HOLLOW STEM <br />a EXTRACTION 0 AIR HAMMER/DRIVEN <br />a VAPOR 0 MUD ROTARY <br />- a AIR SPARGE Ar6USH POINT <br />001L BORING 0 HAND AUGER <br />fl OTHER: eEr6THER CI) <br />*COMMENTS: CFT — <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 I i MULTIPLE CASINGS? a YES NO WELL CASING DIA: <br />CASING THICKNESS _a PE OF CASING: 0 STEEL a PVC 0 OTHER: <br />DEPTH OF GROUT SEAL Af.d,P.- TREMIE TYPE TO BE USED: fl AUGERS a HOSE <br />GROUT SEAL PUMPED: J Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH <br />GROUT SPECIFICATIONS: <br />/6/) 1g...-0 BOLTED TRAFFIC BOX or [I STOVE PIPE <br />( if YES, list specifications here): QONDUCTOR•CASING PROPOSED? <br />("1/1 13,1e14. / <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 />Signed x /436W Title/Company elvD <br />Print Name 01) Date <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br /> Final Inspection By / <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE <br />30 0 <br /> Ii <br />7C-: 5 .6/ Ct) f 4%13 4-, 0 I i# 1 <br />C-57 Letter of Authorization to sign permit en o