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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br /> Date Issued err <br />Date Final Inspection :y <br />Date <br />WORK PLAN DATED: ///1 2-- <br />Area 0(0 <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED <br />3;' 525 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permi <br />INVOICE <br />9/27/00 <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />ENVIRONMENTAL <br />PcPMIT EENICF <br />'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />03 FEB 33 PM12021jZONMENTAL HEALTH DIVISION (PHS-EHD) <br />6.5 mm 03 304 E. Weber, Third Floor, Stockton, CA., 9520 <br />(209) 468-3449 OAT <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU <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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Assessor's <br />WELL Location 2.2..1 t I 1.-5010 )1141 Cross Street ORWOO) City S-P.Z.-r-roki Zip 676-20arcel# <br />PROPERTY Ownerai,;/x t1djor_oe„Teigjairess 5:74)/44E_ City Zip <br />4 <br />Consultant/Sub Contractor:FT:Oa E:OCR Address / 2193 PaDtbepaY Lo r)( Ligi/ `I 752. Phone# 209/768 -q38 <br />GIS Coordinates: X , Y , Township Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />ce1 3 <br />Phone# <br />C-57 Contractor ress, 1-16.0Z-1ZD City t-65a170,_)ezi- elit 4 inkt 5-4z5. <br />1/40DRK TO BE PERFORMED: <br />till"NEW WELL / BORING ( CPT, s.,OPROBE, HYDpnpi Iniru Al ifs= t-rruR*) <br />121N1111 RnRING# e-Prz> <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br /> Grout Specifications: C ( Lao)/ 1.-7" k fr. COOT) <br />$of- 00339C0 *Other_ <br />COMMENTS: <br />TYP,I2 OF WELL <br />, 'ONITORING <br />0 EXTRACTION <br />I] VAPOR <br />fl AIR SPARGE <br />XOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE <br />_ .DLLOW STEM <br />ij AIR HAMMER/DRIVEN <br />Li MUD ROTARY <br />PUSH POINT <br />o HAND AUGER <br />O OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE. 0 MULTIPLE CASINGS? , , ES XNO WELL CASING DIA:, iCkt," <br />CASING THICKNESS 4) - TYPE OF CASING: 0 S EEL 4A 0 OTHER: . <br />(C.417— TREMIE TYPE TO BE USE : El AUGERS .) eFfOSE Ct <br />IDIDTH OF GROUT SEAL <br />GROUT SEAL PUMPED: ees fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') Cy <br />GROUT SPECIFICATIONS: S 10 <br />APPROX. BORING DEPTH I (Al 10 L,. 1ED TRAFFIC BOX or 0 STOVE PIPE <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACH E T PERMITS. <br />CONDUCTOR CASING PROPOSED? It_\ ( if YES, list specifications here): <br />rld 0 17-K, S7L_A ) ) 14/ le Z.- <br />C_Z <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS:, -(2- ( N— GI-ALAN <br /> <br />tt <br />*COMMENTS: c? <br />-.4 <br /> <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 Or3 nces, e tnd R ulations, and all applicable California State Laws. <br />- <br />./ A P A --/T4Ac. <br />6 <br />-F L.) L. L- 12-c 9 6714 L. t-r-Ei (.-• Et 5 /14,0c_e. 1Z.uki <br />Title/Company ()Ctili (Z— F/1)61 (1)C.,P:(2,/ /J6T, <br /> Date VO.S <br />DEPARTMENT USE ONLY