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WELL"'rERMIT APPLICATION FOMA SI A L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> p (209) 468-3449 <br /> UU�v[ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is he by 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 vclrtnment Title.Ch Dter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> `!� s' crr�hx.n,< .114- Assessors <br /> WELL Location I&( Cross Street 11"61 iH ..� City i�T °f Zip N,` Parcel# <br /> PROPERTY Owner C�rt'f OF Lam• Address iva- City .* Zip ! j:! Phone# N P" <br /> C-57Contractor FSU+ E���n���ICress39� SLS PLRc� Ci SPr�'.t3 ZI 95Z5 6Ff3ff6S <br /> ry p zLic# Phone#�zog�h7Z-3$"7) <br /> SCra. f�n� 654498' <br /> Consultant/Sub Contractor -S"�^r"r'o"^�-Address 3oi7 1U�4 �- City�oo� ^ Lb# Phone#�91t,)Cfal-oyo0 <br /> 1.�r r <br /> GIS Coordinates:X N� ,Y N ,Township N Range N h- Section "r <br /> WORK TO BE PERFORMED: <br /> ,fl NEW WELLRI (CP�;GEOPROBE HYDROPUNCH,HAND-AUGER,OTE -) 0 DESTRUCTION(choose type below) <br /> RING r <br /> #S1p-Z T4t >^' 6P-sS p OVER-BORE <br /> [)WELL# 0 PRESSURE GROUT <br /> 'Other.VAf-1 o.>y C�r�?zorz— Pl*" ut Specifications: C <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES MULTIPLE CASINGS?a YES ONO WELLCASING DIA:'-r- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS —A TYPE OF CASING: 0 STEEL 0 PVC BOTHER' A.P� <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL n!A- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE rt1PUSH POINT GROUT SEAL PUMPED: 0 Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> '[SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: '%"" <br /> 0 OTHER—0 OTHER APPROX.BORING DEPTH (S r 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? +vim (if YES,list specifications 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 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 /> Signed Iy'N� Tide/CompanyT� <br /> Print Name IVPZI mr— 'f• PA41C—<. Date (ZOo Z_ <br /> DEPARTMENT USE ONLY( <br /> SITE MAP IN UNIT IV FILE, ADDRESS: mg(17-0 `s' y`7J—+�y� Ye I/ <br /> WORK PLAN DATED: ' 2,7 '-02-- <br /> Application Accepted By Date Issued 5-11( 0 64W <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: c— <br /> ACCOUNTING ONLY: AID# <br /> rerx <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> X 29 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit=Encroachment dor_ 9/27/00 <br /> 6*Y/ <br />