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rY E OF WELL <br />MONITORING <br />] EXTRACTION <br />] VAPOR <br />] AIR SPARGE <br />] SOIL BORING <br />] OTHER: <br />INSTALLATION TYPE <br />[] HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />U OTHER <br />'Sr <br />LI <br /> Date <br />Date <br />kpplication Accepted B <br />3rout Inspection By <br />)estruction Inspection By <br />.10MMENTS / CONDITIONS' <br />Date Issued /0 3/07 <br />Final Inspection By <br />Area qg <br />Date <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 />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />\pplication 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 Developme itl Cha r 9-111 anditie Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />NELL Location,, I A .._c _1 Cross Street City 5-tva.iovi Zip Parcel# — <br />Assessoes <br />0'11 il fvcioLS (5'vti - ) <br />City — Zip — Phone# - 3ROPERTY Owner I Address <br />______ <br />it Dkil 1 I eir Addressain OM/ al( citykeia °ip057/tiLic#.71 610 Phone# Pi()(1).38-11 bli <br />,(2-a-06 I11gi11t10144 !Address 13 16 1 ti 0fl ,IOt 9.(Siitty? 4-Nt 410 Lic# Phone# (q 1 (P) tebt- 044(A) <br />AfORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # , <br />"SSVELL # ci\VI -77t717 tr,17-17-4- cli,—(XiA;t11.9 <br />'Other: Grout Specifications: <br />DOMMENTS: <br />CONSTRUCTION SPECIFICATIONS (00MA ‘I‘tdiS) <br />COMMENTS: Weii MO1 (1444-1 bt ttilstittkcok mill 01 <br />T <br />wcii 100-110' <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 />Signed x <br />rint Name <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />j /AM <br /> <br /> Title/CompanYW jUk 5Ett) 1114CA(111knling11 11V, <br />DEPARTMENT USE ONLY <br /> Date 41(.03 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />NORK PLAN DATED: <br />;-57 Contractor Q( <br />.3onsultant Sub Contractor <br />q6-62.to <br />3IS Coordinates: X , Y , Township Range Section <br />[j DESTRUCTION (choose type below) <br />[i OVER-BORE <br />[] PRESSURE GROUT <br />WELL CASING DIA: <br />TYPE RIF CASING: U STEEL 'PVC 0 OTHER: <br />0311111-9REMIE TYPE TO BE USED: a AUGERS HOSE <br />Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATION:?)(.A/111) <br />APPROX. BORING DEPTFg 0 21i XBOLTED TRAFFIC BOX or U STOVE PIPE <br />COND,UCTOR CASING PROP? ( if YES, list specifications here): <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS? I] YES <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE _ # INVOICE <br />ri — ‘Lob7 -7 0 X ii 111)3 Fut 0 e) .36 00 ') <br />C-57 <br /> <br />WC -WAIVER <br /> C-57 Letter of Authorization to sign permit 9/27