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WELL �RMIT APPLICATION F0o9 I Y <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 and/or 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 Division. <br /> WELLotation I64S`/ $. o-'Ot3� Cross Street �thhr W- pity Zip QS , Parcel# <br /> L «wl d <br /> 196-y3o-IS- <br /> PROPERTY Owner lE1-tE-'y PO)LL'1 495 Address 15133 5. icy¢o-ci�ty+f *`aP Zipg533C`Ph,ne# ! -: <br /> FiSFN C.Ju�.t�wM ?titAddress341 SN't�-1� PtAo� p;tyySP•''^f3S Zip`f5zs2Licu$3fC6SPhone# C2o9�772-35'7J <br /> C-57 Contractor Ggy Y98� <br /> 3ot7et�ya� tio- a/1Nt1i� 011.)EV_ <br /> Consultant/Sub Contractor SCtc r_. 'cc'rwRW-AC ddress •T� o City Cy.cooJP' Lic# Phone# <br /> 6. <br /> GIS Coordinates:X ,Township S airO Range 3 g w Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WEL / RI (CP GEOPROB HYDgOPUNCH,HAND-AUGER,OTHER`) 0 OVER-BORE <br /> SOIL BORING# E'1V 1 <br /> 0 WELL# O PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING U HOLLOW STEM DIA.OF BOREHOLEMULTIPLE CASINGS?BYES ONO WELL CASING DIA:'VA- <br /> 0 EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC o OTHER: AA4- <br /> 0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL__A- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE rPUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VSOILBORING 1]HAND AUGER GROUT SPECIFICATIONS: N'#" <br /> B OTHER: R OTHER APPROX.BORING DEPTH 1 S U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> 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 /> Signedx 1 y' �— Title/Company SIV F7`°LOr'15T SlT`d.�S`rE"�",`i'7`:J^1cf t.uC <br /> Print Name �DM�� y Pte'"� Date Y�Ly'OZ <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE, ADDRESS:��f� Ty -5- <br /> WORKPLAN <br /> WORKPLAN DATED: Z -Z 7-O Z - <br /> r - 06 <br /> Application Accepted By Date Issued D4rea <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: '�- <br /> ACCOUNTING ONLY: AID# =era <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 356 Sz3 31 spit 06 2,1 <br /> C-57-41- WC WAIVER_ C-57 Letter of Authorization to sign permit_C Groo—In n^eat-das_ 9/27/00 <br />