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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />Date Issued <br />Date Final Inspection B <br />Date <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br /> SITE <br />MITIGATION <br />UNIT IV <br /> <br />Oki -1AW <br />aat <br />Cross Street 6/Car--t _City S-6.14:11., Zip Parcel# •060.33 WELL Location 42 a 10 • LULA-a-- <br />PROPERTY OwneriNd4.1.1fcidt•-fe Fise-4-4/4eldress Be,Ack City Siocklts, Zip Pho„# <br />C-57 • tractor \I 4.kAJ Address MO S11` S4(4ek- City TS tcfrAul Zip Lic#720904 Phone#nt6 <br />Address / inaa)k, city F-sraton Lic# Phone# 3S- 9S%5s <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 />Assessori tq. <br />Sub Contractor <br />GIS Coordinates: X Y Township Range <br /> <br />Section <br /> <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE 1 <br />0 PRESSURE GROUT <br />Grout Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE I'm MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: 21/-I <br />CASING THICKNESS Sc,IA L-40 TYPE OF CASING: 13 STEEL jz PVC 0 OTHER: <br />DEPTH OF GROUT SEAL ' TREMIE TYPE TO BE USED: IKAUGERS 0 HOSE <br />GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: LC LJ bennArri:.-402 <br />APPROX. BORING DEPTH /0 0 ;Er BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />Serekki ikikrv-4A ?5"-- 1.6.4,- 5 o.ett <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 this application and that the work will be done in accordance with San Joaquin <br />County Ordinaj'ces,,R6iand Regulations and all applicable California State Laws. <br />WORK TO BE PERFORMED: <br />OVEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*)t <br />0 SOIL BORING # <br />lrELL # 1%/14.4A1 I h <br />*Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING picHOLLOVV STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />fl AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: <br />Signed x <br /> <br />.461 <br />ST10 4:co-vet, <br /> <br />Title/Company eoic,cf rsP/4‘?1.(-7 —xic <br />Date Lip-0- <br /> <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 262(0 2— . LiJtJni. i <br />WORK PLAN DATED: .oz_ <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # R 'D BY DATE / P UEST # INVOICE <br />NW .61 oaq1-3 9.LY sRtt 603552 / <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign per c 1/25/02 <br />