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WELL PERMIT APPLICATION FORM <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 />SITE <br />MITIGATION <br />UNIT IV <br /> <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 <br />ft <br />9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location 2-IfiC- KV Ct5f- ,* 9ee•1 Cross Street Setkl-Stlitr;11/1-titY 5"/OCkit4 er Zip p ?-O& 3S <br />, Assessor's <br />WORK TO BE PERFORMED: <br />/VEW WELL / BORING(tPT, GEOPROBE, HYDRO PUNC HAND-AUGER, OTHER") <br />„.sMSOIL BORING # <br />WELL # <br />*Other: Grou ecifications: <br />COMMENTS:a - eir bor. 4,113 le 6,cpm,ke goe / ,e11 u47 /$zg <br />TYPE OF WELL <br />4.MONITORING <br />O EXTRACTION <br />0 VAPOR <br />U AIR SPARGE <br />XSOIL BORING <br />X1 OTHER: 0,pr <br />INSTALLATION TYPE <br />HOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />U MUD ROTARY <br />)1(PUSH POINT <br />HAND AUGER <br />U OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ,-?.11 MULTIPLE CASINGS? 0 YES 'NO WELL CASING DIA: A•VA <br />CASING THICKNESS /17/A TYPE OF CASING: 0 STEEL U PVC ; OTHER: Aft/NE-- <br />DEPTH OF GROUT SEALIP 1,4,t4adt. TREMIE TYPE TO BE USED: • • ..;.44.4.- a HOSE <br />GROUT SEAL PUMPEDAC'es fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS:Azei-r CENE7117 — <br />APPROX. BORING DEPTH 12.0 pt/14 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <br /> <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 <br />County Ordi es, ules and Regulations, and all applicable California State Laws. <br />Signed x J Title/Company AL_ 041 41 /5 <br />PROPERTY Owner Ra4,0 CLL(,1'A Address /53G Al. 4(/fl1ev .54 City5it/C41191i Zip Phone# <br />C-57 Contractor&pri Address 95b Kai City MI (41V1,0,7- Zip CA- Lic# Phone# 925- 3/3 -5F01) <br />Consultant / Sub ContractorC0i4prhaititt Tee • • • ',5AddressiNAtitk W e .TCityS44461 Lic# Phone#D923/-05711 <br />GIS Coordinates: X , Y Township Range Section <br />a DESTRUCTION (choose type below) <br />0 OVER-BORE <br />eNZPRESSURE GROUT <br />Print Name R.0136Er <br /> <br />Date <br /> <br />DEPARTMENT USE ONLY <br /> <br />SITE MAP MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED. <br />_Art, <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date3 <br />Date <br />Date Issued <br />4,6 7.Einal Inspection By <br />-- ...... -.. — --........___. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # EC'D :Y DATE PER. INVOICE <br />i C ii. l <br />0 <br />c, p)- - 'Inn <br />C-57 Letter of Author4zctidntà sign permit .._. rum..rtmern C-57 -WAIVER