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WELL PERMIT APPLICATIONI�FORM <br /> 1� SITE <br /> NW 0 7 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH I SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (OHS-EHD) UNIT IV <br /> Pl I <br /> 304 E.Weber, Third Floor,.Stockton, CK, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRM 1 YEAR FROM DATE ISSUED <br /> application is hereby made to San Joaquin County for a Permit to construct and/or install the work desclWd. This application is made In compliance with San <br /> iciaquin County Development Title,Chapter 9-1115.3 and the Standards of Son Joaquin County Pubk Health Services,Environmental Health Division, <br /> HELL Location, 16,01 Jr- A. Street-22City 11 Assessors <br /> 1146-1'et "16 -3 72Ae&7V4,0 zip .-Parcel# <br /> $R0PERTYOWn0T Address /f 76 0. CA64kt"k&Q Yi I Ny -Zip 1pj-zp.T Phonei#!�ar'R pox-f <br /> 7 ii <br /> *-57ContractorZ-:;Ag�r" A2A<"f,.ye, Address_9XV Akkj4 &2,AQ CItYAj&_tr-L.U1-7iP_f tS__aickPhcne# <br /> 'consultant/Sub Contractor Address —City_Ljck._PhoneA�_ <br /> lr <br /> ;IS Coordinates:XY Township Range 1 Sec4on <br /> RORK TO BE PERFORM <br /> DR NG <br /> )NEW WELL i e( JNG SCPT)G-EOPROBE,HYDROPUNCH.HAND-AUGER,OTHER'} 1� dDESTRUCTION(choose type below) <br /> 13 SOIL BORING# [I OVER-BORE <br /> 'Other. <br /> WELL# 11 PRESSURE GROUT <br /> Grout Specifications: <br /> ,10MMENTS: 2 500- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z_.Z [I_MULTIPLE CASING$? YES*0 WELLCASINGDIA. <br /> EXTRACTION a AIR HAMMERrDRIVEN CASING THICKNESS TYPE OF CASING: .1]STEEL a PVC 11 OTHER: <br /> 3VAPOR MUD ROTARY DEPTH OF CROUT SEALP&&L_FP&fi4R MIE-ry C TO BE USED; aAUGERS MHOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: AYes 11 No (NOTE: MAXIMUM IFRE.E-FALL DEPTH IS 30') <br /> 1 <br /> )(SOIL BORING HAND AUGER GROUT SPECIFICATIONS: 'OVA rd. "o 7- A � 6&t 7V-ice <br /> I OTHER:6 P-r [I OTHER C,41- APFROX BORING DEPTH 1100' L1 _13 BOLTED TKAFt-iL,wwx or GSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A--*P (if YE6,list specifications here): <br /> 'COMMENTS: CdL 6,F-,4"Viiiit 62A <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 C hereby e have prepared this application and that the work wiR be'done in accordance with San Joaquin <br /> County OrRules and Regulations,and all applicable California-State Laws. <br /> l3 G <br /> Signed x _rjde1ComPany ljg_ ,�7- <br /> Print Nam Date <br /> DEPARTMENT USE ONLY 'r <br /> FILE,ADDRESS: /(,o - <br /> e <br /> SITE MAP IN UNIT IV F 4 <br /> WORK PLAN DATED:. 11 b1 ju <br /> J <br /> Application Accepted 13y Date issued Area <br /> Grout Inspection By Date I I Lt!Nc2( --mnai Inspectio;i By 40=d_ <br /> pateQ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY; A109 <br /> RECD BY DATE Im.tl` rr jsERvtcr=REQUEST log INVOICE <br /> -3 <br /> FEE INFO AMOUNT REMITTED CHECK# FWC' <br /> -3 9 10 Is <br /> C-57 WC__.-WATVER. C-57 Let-ter of Authorization to Sign permit/ Encroachment doc— 9127100 <br />