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JIDESTRUCTION (choose type below) <br />J AN 1 6 2:Orti I B OVER-BORE <br />a PRESSURE GROUT <br />zcA <br />WELL PERMIT APPLICATION FRM <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 />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 />Assessor's 2 23_ z30 -13 <br />Cross Street WaSilicy+0 kCity A/la9 5- q+ex Zip 957-46 Parcel# WELL Location 70.7 E4.5+ (jitY3../7/ii`e <br />PROPERTY Owner A45. il4071(u) Po yi4e5 Address .70-7 R `-(2)erfroriq Ate. City ./1/1c2fr1 +eta. zip 953,76 phoneti?ex;),Q) 3- ,-7.5-F <br />C-57 Contracto4voliced 6e0410it6/1/11oAldress 4-1,0S- A), C,)) SOO (.LCry City)/Ocricja,-) Zip95)05-Lic#C7M17Phone6)04Y--/6) --/€06 <br />k.) <br />Consultant / Sub ContractorMLOYIced Gydeovi.ronfroAhdress goo5..0. ci <br />ty <br />s)Lockkin LiC# 69,0) Phone)te (767 Ya210 <br />REtr7WED---) GIS Coordinates: X ,Township Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />160IL BORING # fi'? - p_., , <br />a WELL # <br />*Other: Grout Specifica •0 . <br />PERMIT/SERvirFS <br />SITE <br />MITIGATION <br />UNIT IV <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />U MONITORING a HOLLOW STEM <br />O EXTRACTION a AIR HAMMER/DRIVEN <br />II VAPOR a MUD ROTARY <br />-O AIR SPARGE V'USH POINT <br />%soil_ BORING a HAND AUGER <br />O OTHER: OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ,2l1 MULTIPLE CASINGS? BYES VIO WELL CASING DIA: <br />CASING THICKNESS ,A1.4 TYPE OF CASING: a STEEL ['PVC El OTHER: <br />n .. <br />DEPTH OF GROUT SEAL 0 n .1-r.t.., TREMIE TYPE TO BE USED: a a AUGERS l io3c;-oek <br />GROUT SEAL PUMPED: [J Yes jp(lo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: (34 I 6 5,uck -1-c., 67 ,4110(6 wifeer <br />APPROX. BORING DEPTH OS s 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? .A1A— cif YES, list specifications here): <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />n <br />Signed x ..e.--, A Title/Company 9kt3r-05 6 ed ey/54/14(rr <br />Print Name FOC /Ca\ M 1'1 1/1/100 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1LI Ai sf oo 0 <br />e r Date Issued &VIA.- I Area <br />Application Accepted By <br />Grout Inspection By Date 6 nj5 ) Final Inspection By Date <br />Destruction Inspection B Date <br />LAJIVIII/MN I J / ‘0 01,11./1 i Par. <br />ACCOUNTING ONLY: AID# 41§Mililfgai*gb. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DAT IT! SERVICE REQUEST # NVOICE <br />3 S 0 • 0 -. .1 0 : 0 6 ?a 044. <br />- . . n !i7 Inn <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authori to sh p,érmit_ ncroac men <br />