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• <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JpA(lUIN COUNTY PLyBLIC HEALTH SERVICES UNIT 1V <br /> ri <br /> t ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 4683449 <br /> R FROM DATE ISSUED IianGe w th San <br /> NON-REFUNDABLE P RM EXP RES 1 be lication is made in camp <br /> for a permit to construct and/or install the work described• This app (t,cge8sor <br /> Application is hereby made to San Joaquin County r- 95 1J°f Par <br /> r� 3_15o -V< <br /> meet San Chapter County <br /> .3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> Joaquin County Develop City ) � Zp <br /> 351 CV S �n� _Cross Stmt <br /> WELL Location Ci �� Zp 95 <br /> A Address �`i��5 5. C�.—;5,>w. ty 35 3i"— - r✓ <br /> PROPERTY Owner ,_j r�C f s� r-&7 `tyj"'U(7-4 L hone# <br /> p� Hc�A�� clry��>x.�i^�p 9--�� <br /> Address=l Phon "tri <br /> C-57 Contractor— �J ; �LidF <br /> dress } <br /> Consultant t Sub Contractor � 0� Range TownshipSection <br /> Y ,Yowship <br /> GIS Coordinates:X type <br /> ❑ ❑DESTRUCTION( b <br /> elow) <br /> WORKTOEF PBEORRFTOfAD AJCEOTHER') OVEROE <br /> #RNCH,SoPgPRESSURE GROUT <br /> W M <br /> $NEW BORING <br /> — <br /> QWELL# Gro Specifications: <br /> 'Other: <br /> COMMENTS: � <br /> INSTAL t ATION TYPE CONSTRUCTION SPECIFICATIONS O WELL CASING DIA: <br /> TfPE OF WELL �j :' MULTIPLE CASINGS?Q YES PVC ❑OTHER:______ <br /> HOLLOW STEM DIA OF BOREHOLE ' <br /> Q MONITORING ❑ TYPE OF CASING: [j STEEL Q <br /> Q FRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: []AUGERS Q HOSE <br /> ❑ DEPTH OF GROUT SEAL <br /> MUD ROTARY <br /> Q VAPOR GROUT SEAL PUMPED: Yes 1]No (NOTE: MAXIMUM FREE-FALL- DEPTH IS 30", <br /> Q AIR SPARGE PUSH POINT <br /> ❑ <br /> GROUT SPECIFICATIONS: ` STOVE PIPE <br /> `,SOIL BORING �]HAND AUGER BOLTED TRAFFIC BOX or <br /> APPROX.BORING DEPTH <br /> f=S,list pecifica�ons <br /> 'QOTHER; l' --� ONDUCTOR CASING PROPOS�D? (if Ys <br /> OTHER here)' <br /> 'COMMENTS: <br /> NOT <br /> E: OFFSITE BORINGS REQUIRE ACCESS OR ENGOROACR Qu REQ PERMITS. <br /> CALL THEW ....IV INSpEGTOR 48 WORKING HOURS IN ADVANC <br /> that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> I hereby certify t ulations, and all applicable California State Laws. nU- <br /> County Ordinances, Rules and Reg Litle1Company <br /> Signed x _ <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: � — <br /> Date Issued %%�� ? �V Da <br /> Area— <br /> tr- <br /> Application Accepted By Date Final Inspection By <br /> Grout Inspection 8y Date ,7 <br /> Destruction Inspection By � f <br /> COMMENTS I CONDITIONS: <br /> O J•, <br /> ACCOUNTING ONLY; AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK if <br /> RECD BY DATE PERM !SERVICE REQUEST# INVOICE <br /> d o 2 4 S"4 2 <br /> dA01 it _ tilG - 9/z <br /> m <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachent doc <br />