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Date Issued <br />Final Inspection By <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 />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. <br />Assessors el 0 <br />WELL Location Location 21# 6. PA-Ric. 57. Cross Street-54AI &ova wioSr City c-rixgronJ Zip 1.526.1 Parcel# <br />Address /534 A.). mAirsia S:r City 51-00_/1.."-pAj Zip 95202 Phone#C7499),074434 PROPERTY Owner Aft. PAttese, 64,u&p.14- <br />C-57 Contractor F-1441760 GC-oScuraJe.Asi jave.Address 001)8goviwai )5m 440 City 01144.4141.0 Zip (4/60"/ Lic#7i120/.3 Phone#(6io) 24,7 -442.8 <br />Phonetc,097)234--43.51-Y Consultant! Sub Contractoreemate &PTA Tug Lue._ Address Mg g2A/O/LkJAssr coar_a_ ab6rber.j,...) Lie* <br />, Township Range Section <br />EOPROB 4.YDROPUNCH HAND-AUGER, OTHER") 5 SI a DESTRUCTION (choose type below) <br />0 BOIL BORING # <br /> 0 OVER-BORE <br />*Other: Grout Specifications: TrIPE -Ziff c-enA4A.n- j 4 ,c,.. RelurbAJ1170 <br />COMMENTS: 5 cPr Boomue.< -rb ao '; 5 /2wutj Sbr./A5G.1 -17)/5th ' j I GLbpeiniltr it) <br />(:1 WELL # <br /> 0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.5 " MULTIPLE CASINGS? U YES ,)('NO WELL CASING DIA: 1)4 <br />0 VAPOR <br />EXTRACTION <br />(:1 MUD ROTARY <br />AIR HAMMER/DRIVEN CASING THICKNESS A.)/A. -TYPE OF CASING: 11 STEEL U PVC ri OTHER: <br />CVTH OF GROUT SEAL TO 514P.FA44 TREMIE TYPE TO BE USED: 0-,APARCS HOSE <br />GROUT SEAL PUMPED: VYes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') XPUSH POINT <br />GROUT SPECIFICATIONS: i4)4i4 (-$A/J 7 <br />a AIR SPARGE <br />(:) HAND AUGER <br />APPROX. BORING DEPTH /5_4(f)U BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />(:1 SOIL BORING <br />U OTHER XOTHER: ciar <br />CONDUCTOR CASING PROPOSED? Ait, ( if YES, list specifications here): <br />*COmMEN TS: 11-7"7-61vIA 7 5- CPT 5014 AIN $Jc 7b "--/Sn flAt.u..Ttpt-g /11A../4 <br />,54 P`4,P 1--S -r1I-E 5 CPT Si -MS ; A-g) 1 SO11-.1300P-1A9A___CS), / rrif - cior s/ 76 <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 Ordina ces, Rules and egulations, and all applicable California State Laws. <br />Signed x Title/Company_5—:72FFF G9.o, 5 r <br />ta ITC X <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />50 <br />c:04 <br />Print Name <br /> <br />rP F <br /> <br />Date n o <br /> <br />DEPARTMENT USE ONLY <br /> <br />Date <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection <br />COMMENTS! CONDI <br />. . <br />1.211rear 1 <br />' IONS. <br />IF? , <br />ACCOUNTING ONLY: AID# FAC# <br />FEE INFO CHECK # PE CODES <br />.501 <br />AMOUNT REMITTED REC'D Y <br />3 sRttno31-30 5 <br />DATE PERMIT /SFPVIC.F_RFCTOEST4 Nr INVOICE <br />a <br />r_A7 \A/c. _1A/ATVPD C-q7 I n tn nermit 9/27/00 c c