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SITE <br />MITIGATION <br />UNIT IV <br />WELL PERMIT APPLICATION FuRM <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 />1 -221c) Date 7D <br />Date <br />Application Accepted By UNNAit,tn. <br />Grout Inspection By t.A,,AJNAn rvt <br />Destruction Inspection By <br />Date Issued // Area <br />Final Inspection By kAT"--(ii.Anec--.. Date <br />Date I ./11/017? <br />DEPARTMENT USE ONLY <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 />WELL Location0 5-0 "Tor-flre Cross Street&-Orilihe <br />PROPERTY Owner \IC -rcik Address 9•460 -to* 9.3 <br />C-57 Contractor 6 D1 Address Address 6150 i-kjje_ <br />Consultant / Sub ContractorAd-tia k7c-eS fec)P4U , Address <br />GIS Coordinates: X Y , Township <br />V,K TO BE PERFORMED: pEi <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROF'XCH, HAND-AUGER, OTHER* <br />400IL BORING # <br />DWELL # <br />Other: <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />U MONITORING 1:1 HOLLOW STEM <br /> <br />O EXTRACTION AIR HAMMER/DRIVEN <br /> <br />VAPOR UMUD ROTARY <br /> <br />-U AIR SPARGE •OUSH POINT <br /> <br />SOIL BORING Q HAND AUGER <br /> <br />a OTHER: U OTHER <br />*COMMENTS: <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 Ordi ances, Rules a9fiReguIations, and all applicable California State Laws. <br />Title/Company <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 7 nC+611-er (3.000 <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# <br />PE EST # INVOICE <br /> •5/7/0/ <br />C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />_ F A C # <br />PE CODES FEE INFO <br />3 S.--0 I <br />AMOUNT REMITTED CHECK # <br />I k-V4-3b <br />REC'D BY DATE <br />C-57 WC -WAIVER <br />City <br />City Tro zip 537b PAasrgis#scP3 - <br />City Zip qc74 Phone/00?)-'g3.5-7- 6”Y <br />Lic#A5161,Phone(9- 15/3 7.5S N\ <br />city Lic#6e0,1...??Dhone#*9)\/6706) <br />DESTRUCTION (choose type below) <br />U OVER-BORE <br />1] PRESSURE GROUT <br />Grout Specifications: <br />FEB 2 6 2001 <br />Range _ <br />- <br />ENVIRONINIFNI FIF:-ALTH <br />PFRMIT/SERViCES <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 9-)1 MULTIPLE CASINGS? a YES LI NO WELL CASING DIA: <br />CASING THICKNESS .4)76r TYPE OF CASING: fl STEEL a PVC El OTHER: <br />DEPTH OF GROUT SEAL E (Ni o HOSE <br />GROUT <br />TYPE TO BE USED: -11-PkGfitr-"S <br />GROUT SEAL PUMPED: Yes XNo (NOTE: MAXIMUM FREE <br />.FAccbtrm is 3S0E1 <br /> <br />GROUT SPECIFICATIONS: s i c k Pod-lot-4i -iv 6 yailons C-- <br />APPROX. BORING DEPTH 6 0) U BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? / (if YES, list specifications here): <br />Signed x <br />_-c)/(3? <br />n <br />Section