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• R • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <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 andlor 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 <br /> Health <br /> e ll SDivision. <br /> WELLLocation Qo� S /dCtrDY0. sf Cross Street Crt ,n City c hzpgSAojAssels 1r's 3140-0! <br /> PROPERTYOwner F14Y fc-, t� ±aVoYSdAddress Pt7 g,,,�277g Ciry ✓FNft'SZip23b0'�Phone#7.S/.87y 7795 <br /> C-57 Contractor F., RobC Address 1 0•&x 6013 !ary0%.i It' Zipj5%/CLic#777007Phone#S30 _5 .201° <br /> Consultant/Sub Contractor /1'Y Frt Vi✓dczl ::4<Address.S$WPri' rcu,*= Ciry sir Lic#Phone#x/(».535 OaC.2` <br /> GIS Coordinates:X ,Y ,Township-1-0—Range (O f= Section 9 <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> JEW WELL/BORING(CPT,GEOPROBE,HYDROPUt�LCHH,HANDAUGJ;yR$OTHER') 0 VER-BORE <br /> 5S SOIL BORING# b //�R <br /> W ELL# <br /> ?R URE GROUT <br /> •Other. Grout Specifications- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE. 3„_MULTIPLE CASINGS?0 YES NO WELL;C?ING DIA: 1 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Al/� TYPE OF CASING: 0 STEEL 0 PVC BOTHER: rrf <br /> 0 VAPOR O t�UD ROTARY DEPTH OF GROUT SEAL �� C I�TREMIE TYPE TO BE USED: GAUGERS OSE <br /> p RSPARGE ■■PUSH POINT GROUT SEAL PUMPED: es pNo (NOTE: MAXIMUMFREE•FALnLDEPy^H�IS30' <br /> VOIL BORING aHAND AUGER GROUT SPECIFICATIONS: Gr .+-rO I D-COtI+ -/0 4 ri-uCC- (�O�+IQ-M L+R <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 46 a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r CONDUCTOR CASING PROPOSED? oVo(if YES,list specifications here): <br /> *COMMENTS: Y/YlI]/ iOr SOi Qnd Cy�ouvc��-n.�Y�' �+r�/C CO//C �'OI't. �vir.A.tii ll be d<s�tov�' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4t$WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 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 /> Si nedx / L/�/ Title/Company <br /> 9 T <br /> Print Name v fir”� 0 <br /> Date -0a <br /> DEPARTMENT IU.SE ONLY <br /> ,y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /I o?' 5 '�"�" l <br /> WORK PLAN DATED: Z /- 3-Q 2– <br /> Application <br /> Appfication Accepted By <br /> Date Issued 3 ' I Z O Z-- Area 6�- <br /> Grout Inspection Brj Z Final Inspection By to <br /> y - <br /> Destruction Inspection By Date 2 <br /> COMMENTS/CONDITIONS: . <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ?Ao �� 9 pZgl3 8 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/0/ <br />