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WELL PERMIT APPLICATION FORM <br />RECCE Wni <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />MAY 1 4 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />WC C-57 -WAIVER men oc <br />017.:462 <br />C-57 Letter of Authorizati ign pefit <br />/\ <br />SITE <br />MITIGATION <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 m <br />Joaquin County Development Title, Chapter 9-1115.43s,nd the Standards of S•gp Joqgyin County Public Health Services, Environmental Health Division. <br />1-3 /e,e K viec s4_,:z.id,vi . crs-2---) Assessor's <br />. "Pat-)/14*161,---'' Cross Street ' ity Zip Parcel# WELL Location <br />hone# 351 ( <br />C-57 Contractor t4)(45+14/6,2- 61-4V---Address aggfis--falyt /k Cityyt}ip ''i51/.2-Lic#5517/?nhoneek.=)6?-72'74, <br />Consultant / Sub Contractor <br />GIS Coordinates: X , Y , Township Range Section <br />"IK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') ), 3 <br />.---), <br />U SOIL BORING # <br />El WELL # <br />"Other: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIpS <br />DIA. OF BOREHOLE g3 1 16 rviULTIPLE CASINGS? a YES 0 WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL ,a...Pk+C O OTHER: <br />DEPTH OF GROUT SEAL (25-- P6.1---TREMIE TYPE TO BE USED: AUGERS a HOSE <br />...--, t J <br />GROUT SEAL PUMPED: B Yes ,or, (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') •• <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 45-- - , 1 5•OLTED TRAFFIC BOX or a STOVE PIPE <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 WAAL- I /71 II r/..g. Title/Company AG U---- <br />Print Name IA) a k;:A..- LIT-T714.--) Date 5-- I17? <br />DEPARTMENT USE ONLY <br />514 <br />Date Issued <br />Final Inspection By <br />ern kt_ 642 dict_1l 04-- iny/ d (t) jit Of F;6 140 <br />‘4,0 llllll a-•• . ,..• I S•••••••.••••• ••••••••••• <br />ACCOUNTING ONLY: AID# FAC# <br />exr-t Fccc I-Et C i crff- tA)cLIV. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC/D'16774E PERMIT / SERVICE REQUEST # INVOICE . <br />( 372/4V j/j SR# 091-, _ <br />ENVIRONMENT HEALTH <br />PER <br />PROPERTY OwnerS7iirx-Ott-\)74 glliAddress42-5 City5-ht zipq5zbzip <br />Address037 slevotA..) AIL.CitySicalevlic# Phone# zvz en6 <br />fl DESTRUCTION (choose type below) <br />U OVER-BORE <br />O PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL <br />O MONITORING <br />O EXTRACTION <br />a VAPOR <br />O AIR SPARGE <br />a SOIL BORING <br />a OTHER: <br />IA CONDUCTOR CASING PROPOSED? A44- ( if ES, list specifications here): <br />"COMMENTS: (ZY-OVI\ b M,OArrabvilo <br />INSTALLATION TYPE <br />El HOLLOW STEM <br />O AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />a PUSH POINT <br />U HAND AUGER <br />O OTHER <br />SITE MAPMAP IN UNIT IV FILE, ADDRESS: <br />a.( 4 WORK PLAN DATE' 0 <br />Application Accepted B 111.117..illib. <br />Grout Inspection By /Mit _ <br />Destruction Inspection By <br />gi _51-Er,/&64 <br />iance with San