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ti <br /> i <br /> WELL PERMIT APPLICATION' FORM SITE <br /> i <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 100? 1, 0 '` ENVIRONMENTAL HEALTH DIVISION (PHS-' HD) <br /> E t 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> no, J'. _ (209) 468449 <br /> NON•REFUNDABLI PERMrr EXPIRVS 1 YEAR FROM'DATl=ISSUED <br /> %ppiication is hereby made to San Joaquin County far a permit to construct and/or install the work described. This application is made in Compliance with San <br />! ;or#quin County t?evaiapment Title.Chapter 9-1115.3 and the Standards of San Joaquin County Publie Health iServices,Environmental Health Division. <br /> !; Assessor's <br /> VELLLoaation �6�3 s S T _ Cross Street edy,4-fit Ivy City irp gL206S'Parcel# <br /> >ROPERTY Owner 4-4 1-. 4&X Address / i� E CH Q w City 11 <br /> zip 9S a�PhoneiF Z4 ��8 !�-3 <br /> L <br /> �i <br />' .57 Contractor V d-W 9121 L dress . P. jd-Y. y I City c zip 9y64t Lim?1 mil Phone# F16 777777- 9/510 <br /> ,Onsultant!Sub Contractor Address Clty LiC# lahone# <br /> } <br /> 31.5 Coordinates'X ,Y Township Ranged Contractor- <br /> Section <br /> t ;r <br /> { <br /> NARK TO BE PERFORMED. �, �pESTRUC riom(choose type below) <br /> C 4EW WELL!BOMNG(CPT,'GEOPROUL,HYDROPUNCH.HAND-AUGER,OTHER) VER-BORE <br /> )]SOIL BORING# ]PRESSURS GROUT <br /> 'Other: D WELL ii tv Grout Soedilcalions:. <br /> F <br /> ;OMMENTS; b0.Sr124,c.T/&A1 ;f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS « <br /> MONITORING IOLLOW STEM DA OF BOREHOLE��� MULTIPLE CASINGS, El YES I(NO <br /> WELL CASING D1R�� <br /> ]EXCRACTiON 11 AIR HAMMERIDRIVEN CASING TKICKNESS:LC_* 'f n _TYPElOI✓CASING: (j STEEL PVC fl OTHER: <br /> ]VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 1}TREMIE TYPE TO BE USED: []AUGERS WIOSE <br /> Z AIR$I'AftGE p PUSH POINT GROUT SEAL#'UMPED: Yes 0 No (t30TE::JMAXIMLfM FREE-FALL D>r]'T �H IS Tom'} <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS:N '�TL Ati0 LTt=D TRA BOX or Q STOVE PIPE~ <br /> a OTHER-._[]OTHER APPROX BORING.,DEPTH /470' ? I�O <br /> CONDUC"r6i CASING PROPOSED? �t iiYES,listspeoifications here): <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 app <br /> Ucation and that the worst will'be done inaccordance with San Joaquin <br /> County Ord in s,Rules and Regulations,and all applicable California State t-aw5. <br /> Title/Campany � � e� j ��� <br />` Signed x <br /> Print Nam •Ja-//it/ '1 Dates <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,Ab RESS: <br /> WORK PLAN DATED: 1 <br /> Giate Issued Area <br /> Application Accepted By ( Gy <br /> f <br /> Grout inspection 6y Date t FInal lnspectron By'i �� <br /> Date <br /> Destruction Inspection By <br /> :E <br /> commrzNTS 1 CONDITION a. I� <br /> ACCOUNTING ONLY: AID# it <br /> lpERmwl SERE RINVOICE <br /> VICEQUEST# ICE <br /> FE CODES FEE INFO AMOUNT RFritrrfED CHECK# REC,D BY DATE 1; <br /> 3Oz 60,00 03V?,S 7-- kills <br /> g/27/00 <br /> i Encroachment dac <br /> i a ion <br /> - A I2 L-57'Letter of outlier to sin arm t <br /> z t 9 P <br /> C-57_�� wc..-_ w xv� �. <br />