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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 10 <br />5k06 <br />0/ <br />WELL PERMIT APPLICATION FORM ORIGINAL <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />NOV 0 7 2001 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />U41 <br />5404. 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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location 560 Pac 4ve Cross Street R°611.5x-14")6 City StOor tool Zip cr52 07- Parcel# <br />Assessor's <br />PROPERTY Owner S tO R.. IS rt.) Address 53G8 Ric,c. 4 ve citystocktu" Zip i5).07Phone# 20 9 /52 -‘27-7 <br />WORK TO BE PERFORM <br />ANEW WELL! BORING (C15) GEOPROBE, HYDROPUNC_,H HAND-AUGER, OTHER*) El DESTRUCTION (choose type below) <br /> <br />SOIL BORING # C.PT— OVER-BORE 0 WELL # PRESSURE GROUT *Other: I ( <br />COMMENTS " Grout Specifications: <br />: d,72 ()N <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIF WIONS <br />t I 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE V7/ MULTIPLE CASINGS? 0 YES 4 NO WELL CASING DIA: <br />0 EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 1:1 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ID TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE #PUSH POINT GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />OSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:" FLA,_ ,k 0 OTHER: 0 OTHER APPROX. BORING DEPTH (9i 1 <br />,_ g BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <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 County Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />at,t1)4 4( itle/Company bg,t_ <br /> <br />Date <br />DEPARTMENT USE ONLY <br />eL•41c-- deX, <br />Area ai4 Application Accepted By Date Issued //-1 3 / <br />Final Inspection By Date 7- 2,6-0 2— <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P ' • ST # INVOICE <br />'t 01 -7Z f 7- ,te/4— /4 R# e9,&'2 ?0 5- <br />RECEVE <br />SITE <br />MITIGATION <br />UNIT IV <br />C-57 Contractor G kt.3 Dr' • rj Address 950 1-1014,1e Rd City1aetinev,ipWss3Lic#650/61phone# 5/313 -58°6 <br />Consultant! Sub Contractor 1.. FinV netrillI /44411Address 165004 (*rei n tirifity RiCent‘Lic#64263tqPhone# 7/WA 3.) <br />GIS Coordinates: X V Township Range Section <br />Signed x <br />Print Name n ecjia.wk <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />Date 2Lj°1)d °)095 - - C-57 Letter of Authorization to sign permit E 9/27/00