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Date <br />Date <br />Final Inspection By <br />03/29/02 FRI 12:55 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />ORIGIdt <br />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 />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 Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location LF too 00,,, cross street H-14,-.1 cl city 51C,- Zip /5-'90- PAa5rCesels#32)1*-42'/-5-4 <br />PROPERTY Ownell V10 .1 49 1 Addres s iso 'k COO 4f City S., Zip/4/ TV3Phone# gr ) 76.5s- <br />C.S? Contractor 14/ez )"e f Mal icliV 6 Z- Address I 4t1C -tyt.ve,e44•4_Zip Ts-776 Lic#S33 4hone 76 31-000 <br />Consultant/Sub Contractor 5 c co Tr, 71-, Address 3 / 7 ki InD re IC/City 4451° <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PFIVQRMED: <br />KNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHE,T) <br />WNE11-#41-woeolor 44 P4W 4/‘ /014 /4446 a SOIL BORING # <br />CONSTRUCTION SPECIFICATIONS <br />CIA. OF BOREHOLE 5 MULTIPLE CASINGS? a YES *NO WELL CASING CIA; <br />CASING THICKNESS Sch 9- 0 TYPE OF CASING: a STEEL *PVC a OTHER: <br />DEPTH OF GROUT SEAL1-' TREMIE TYPE TO BE USED: AUGERS fl HOSE <br />GROUT SEAL PUMPED: p Yes tr No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 'at 4.1g J //r c4-er4 <br />APPROX. BORING DEPTH -7 r a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 4./e9 ( If YES, Ilst 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 thls 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 )( )7k-Zr-.-7 The/Company Pr 5c vi i5 le /52 C CI< <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 4/3 a)16 /67 /, 5)/X <br />WORK PLAN DATED: — 2,0 <br />Date Issued <br /> Z— Are3 C6,PV <br />Grout Inspection By <br />DeSINCtiOn Inspection By <br />COMMENTS! CONDrTIONS: <br />ACCOUNTING ONLY: AID# Cilf.# <br />_ <br />r <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D SY DATE INVOICE T# <br />35b ( A-AJAJ -- VT 4/3605/8 76 CI14 3 - V SRN e9t .? <br />SITE <br />MITIGATION <br />UNIT IV <br />ON <br />Phone wo),6-;-aga7 <br />*Other: <br />COMMENTS: <br />U DESTRUCTION (choose type below) <br />IJ OVER-BORE <br />U PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />*MONITORING 'HOLLOW STEM <br />O EXTRACTION a AIR HAMMER/DRIVEN <br />a VAPOR 0 MUD ROTARY <br />J AIR SPARGE a PUSH POINT <br />O SOIL BORING (I HAND AUGER <br />BOTHER! a OTHER <br />Print Name <br />Application Accepted By 1/5?) EJ0))7-1)0N\ h C-57 WC.-WAIVER C-57 Letter of Authorization to sign per 9/27/00 Encroachment doc