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AMOUNT REMITTED <br />Date <br />Date <br />PERMI ISERVICaREQUESTO <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: <br />Application Accepted By <br />.11 <br />Grout Inspection By <br />OestructIon Inspection By <br />COMMENTS CONDITIONS: <br />Date issued <br />2-- Final inspection B <br />rS7) <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />AID# ACCOUNTING ONLY: <br />AIR SPARGE <br />El SOIL BORING <br />fl OTHER: <br />(I PUSH POINT <br />I HAND AUGER (1op59 <br />n OTHER <br />*COMMENTS:_56-r.c 4 77-4 67, <br />U <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 sap <br />Joaquin County Development Title, Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Assessor's <br />WELL Location Z 37 ii//9/1:XL eV /Zo///,, Cross Street /WO /11/4C City 5raerf-nw Zip 95-2 /5- Parcel# //,/ - <br />PROPERTY Owner ...i )/1N //No 0/7/7 7/7/0/4"-Address 6Y/.5- //5Devr/ firCity _.57-0e,errp.1/Zip Phone# /tiA <br />573,,r;" , <br />C-57 Contractor 54Y 4,E4 ExPec.'(//rAddress tiO ,eft./4.eorw4/z,- AeC City-a/Irv-rev ern-Zip 0/1-g r LiCIS C 4/ - Phone* (70 7) W 2 <br />r-y_ a:, <br />Consultant / Sub Contractor 4.1z 4)50e2"," TC Address 9610 Oft-54ptit,rn" Ere/ City $-4^/ 1.21-6:60 LIc#P4-7 1 qtthhoneft‘i,Cte) 5- i-06 92 <br />pis Coordinates: X - /2 1. '1 6 ( 7 •y 37, 9 7 7 65- , Township I 0 hi Range g 6E Section 36 <br />kSCG F,A ) <br />g NEW WELL! BORING (CPT. GEOPFiOBE. HYDROPUNCH AND-AU , HGER. OTHER') a DESTRUCTION (choose typt below) <br />1:1 OVER-BORE <br />WORK TO BE PERFORMED: <br />0 SOIL BOOING # 0 PRESSURE GROUT <br />WELL * , /7 d-/-P. , C_V6-45 - r. i/6;45 -2, rirF//s-.D6)/-, <br />*Oher: <br /> Grout Specifications - <br />COMMENTS: l-Woto3E,1 I.,E4 4 4 ,4‘,-prz-eyas - 4,.,-./; .rt L ri 5 r /Z 4 i-t" on/ 41Ti1e 1.1 0 <br />. <br />rfrl, <br />TYPE OF WELL INSTALLATION TYPE <br />at MONITORING I HOLLOW STEM <br />I EXTRACTION 0 AIR HAMMER/DRIVEN <br />V VAPOR 0 MUD ROTARY <br />ERMITS. <br />NSPECTIONS. <br />with San Joaquin <br />I hereby certify that have prepared this application and that the work will be done in accordance <br />County Ordin nc , Rules a d arid all applicable California State Laws. RjjjflS <br />Illor Signed x ' <br />Tide/company 243 Gc 4.1 4 I C <br />DEPARTMENT USE ONLY <br />SITE <br />MITIGATION <br />UNIT IV <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT P <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED I <br />Print Name <br /> <br />cONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE /0 ZIVL/, MULTIPLE CASINGS? I YES a NO WELL CASING DIA ief Li‘i <br />CASING THICKNESS sc a a a TYPE OF CASING: I STEEL N PVC 0 OTHER: 6 " <br />DEPTH or GROUT SEAL .3g Fr, c i r7r TREMIE TYPE TO BE USED: N AUGERS a HOSE <br />GROUT SEAL PUMPED: Vas u No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: XF Ai 7epw,rr-4-77' valz <br />APPROX. BORING DEPTH 6c-- fr, lie; Fr ii BOLTED TRAFFIC BOX or 13 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list spodfications here): <br />I :: S-. 0- 7 /C.& k/6 e 04/ cric" 17t1 57 - ._- z. 5