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o Area <br />Date <br />Date <br />Data <br />Date ISeued <br />Final Inspeciion By <br />srrE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: n A <br />Appiitation Accepted ay <br />Grout Inspection By <br />Destruction tnepeciion By <br />COMMENTS I CONDMONS: <br />-,•••11• Villa <br />C-57 C -WAIVER C-57 Letter of Authorization to sign permit ErICroaChrfleEt doe 9/27r0C <br />> 1 0 0 <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 />SITE <br />MITIGATION <br /> <br /> <br />11 <br />MAY 0 9 2003 <br />PROPERTY Owner .4. 1 ( .C-------L---‘ AddressL (-)- 0 . 6,, ), 3 .C.__City -,Zpft_,L- 0 phife0 - <br />C-57 Contractor tt:;Tr dress )'City /_,L...,1--..1't ZipLif C 71 Liao_____1( 616° ;PtInett -_2_0_1 - 3 <br />`(, . <br />Consultant / SuO Contractor <br />Addresc <br />Flhonet <br />GIS Coordinates; X____--- Y__----' Towns----- Range <br /> Section <br />13 WELL 0 <br />P <br />CONSTRUCVON SPECIFICATIONS <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />ELI tele' <br />N0 <br />r <br />i.pplicaGon is hereby made to San Joaquin County for a permit to C.onstruct andior install the work de.scribed. This application is made in complianeelwilibtiliaTH <br />loaquln County Development Title, Chapter 9-1115.3 and the Standaeds of Sari Joaquin County Public Health Services, Environmental Heaitri Divisiort;InF( <br />-REPUNOAEILE PERMn' EXPIRES 1 YEAR FR <br />NELL. Locationa:L.5 cross Street --1_-_-3--C11"4' Zip Pak5srceles:les <br />Citt;r <br />M D TE ISSUED <br />'Other: <br />COMMENTS: ) r <br />TYPE OF WELL <br />IMONITORING <br />II EXTRACTION <br />VAPOR <br />fi AIR SPARGE <br />1-SOIL BORING <br />a OTHER- <br />`COMMENTS: <br />( ' ,. . <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Oran es, Rules and Ragt,ations, and all applicable California State Laws. <br />Signed x ------./14 <br />T 1 tie IC omp any E <br />Date <br />de <br />Pnnt Name 7/104/1,5 E K? I <br />5--- -2 -0 <br />DEPARTMENT USE ONLY <br />t <br />MIR TO BE PEFIFORMED: (;) 4:: A (-• cP.f. ,,t_ t".5 ir 4e <br />EW WELL / CPT, GEOPROBE. H DRO UNCH. HAND.AUGER, OTHER') a DESTRUCTION (choose typo below) <br />SOIL BORING 0 - <br />INSTALLATION TYPE <br />)HOLLOW STEM <br />a AIR HAMMERIORIVEN <br />()MUD ROTARY <br />1:1 PUSH POINT <br />a HAND AUGER <br />OTHER <br />4 <br />01A. OF BOREHOLE MULTIPLE CASINGS? D YES ;INO WELL CASING DIA: "I— <br />CASING THICKNESS TYPE OF CASING: D STEEL PVC OTHER: <br />DEPTH OF GROUT S9At..._ TRENIIE TYPE TO BE USED: AAUGERS (1 HOSE <br />GROUT SEAL PUMPED: trees a No <br />(NOTE: MAXIMUM FREE-FALL DEFTH,1S 30' <br />GROUT SPECIFICATIONS; e k,* ro. ' he= t . I - <br />APPROX. BORING DEPTH <br />EOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED? if YES, list speeifications here)! <br />s e I -I • <br />3 ivecJe-,1) <br />PRESSURE GROUT <br />• Grout peclfications: <br />-f a <br />El <br />OVER.BORE <br />AtfAcci) <br />tt,