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Date Issued <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />1 ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />OFF. 00 Row <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessor's <br />WELL Location2h6Z Al 44/Stei- /at Cross Street3eAg144.14. City 516(.144.— Zip Parcel# <br />PROPERTY Owner 34:0 vidiAff 4, IA) ii)) • Address .1 B E a.e....,14-aita-mnlity sktur,-- Zip Phone&M 0 3b57- <br />C-57 Contractor V4 liki Address tb0 S'S-1.. City_Vo4CA-- Zipl Lic# 726104i Phonetti5/0 772-4/0 <br />Address / No Ari..,:-. Si- cit,esrAh- Lic# Phone#(2v5)83e-f S1-1/ ub Contractor 6 2x _i-Adc. <br /> Township Range Section GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />cl,IEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />B SOIL BORING #_ 0 El OVER-BORE 3 friELL # YAW pap A /4- i_ f 1. 0 PRESSURE GROUT <br />*Other: (iv •""/ L PI 1 Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE lax 1/4 MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: Z IAb <br />CASING THICKNESSSCAA q(-) TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />DEPTH OF GROUT SEAL 53 TREMIE TYPE TO BE USED: )(AUGERS 0 HOSE <br />GROUT SEAL PUMPED: )KYes (i No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: fk.RM- /141,4ANt. <br />APPROX. BORING DEPTH 75 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: Ce I Oki ued 55-351 e ywk_ <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 thaav- prepared this application and that the work will be done in accordance with San Joaquin <br />County OrIna AB/ and Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />XMONITORING HOLLOW STEM <br /> <br />0 EXTRACTION <br />fl AIR HAMMER/DRIVEN <br /> <br />VAPOR MUD ROTARY <br /> <br />AIR SPARGE PUSH POINT <br /> <br />El SOIL BORING 0 HAND AUGER <br /> <br />0 OTHER: 0 OTHER <br />Title/Company Gm tA-051 I CY) 't' Print Name Scow 6ctruey <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: .677 /0//(/ <br />WORK PLAN DATED: 4-Zi5 -02- <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RE5:p By DATE INVOICE P VICE R <br />3% 00/Z 94, W S13#'01°355- <br /> Area <br />Date Final Inspection By <br />C-57 Letter of Authorization to sin permit 1/25/02 <br />2eP-0.3 - 2 F ,15 <br />C-57 WC -WAIVER