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FILE COPY <br /> II WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT IV <br /> U/ll ENVIRONMENTAL HEALTH DIVISION (PHS -EHD) <br /> 304 E . Weber, Third Floor, Stockton , CA. , 95202 F <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 Health Division. <br /> WELL Location1 <br /> p sI <br /> `vJ 7� 6 � • Cross Street <br /> • IXtC"6&1 City SZD &47Assessor's <br /> W Zip ParcelAsses# or's <br /> PROPERTY Owner r� IF �h( SE2l� lam. Address 720 N ( 'yy ST. Cityti OS Zip Phone#ILQ��y�y <br /> 3233 iziT xASY • P&Aj * 003) <br /> j C57 Contractor H14ZppDl�ppT-- G Address_: ,� 1 / Cityragwn i} Zip Lic#SSf/979 Phone#/ 27( <br /> Consultant / Sub Contractor N - tN• r� • Address S 3 7 Su AW �• CitySZotfe7on/ Lic#Phone �l Y'6 r l�0 <br /> GIS Coordinates: X., y.0 Township Range Section <br /> li <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> EW WELL / BORING ( GFA- II , GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 OVER-BORE <br /> SELL ILIf OIL BORING # <br /> W �� PRESSURE GROUT <br /> Irl <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ! ' <br /> MONITORING HOLLOW STEM DIA, OF BOREHOLE,, // MULTIPLE CASINGS? YES NO WELL CASING DIA:_ <br /> EXTRACTION 17 AIR HAMMERIDRIVEN CASING THICKNESS 4N Ko TYPE OF CASING: 0 STEEL 0 PVC IFOTHER: <br /> o VAPOR MUD ROTARY DEPTH OF GROUT SEAL 76 ' TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> p AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 9Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 307) <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS: Pa¢ 7`UWO T�'P�/77_ <br /> OTHER: n OTHER APPROX. BORING DEPTH I ' ' BOLTED TRAFFIC BOX or a STOVE PIPE <br /> � � <br /> CONDUCTOR CASING PROPOSED?�__ ( if YES, list specifications here): <br /> *COMMENTS: Dal% ljl (I/lUL7/ �I•IN.t f� ( �iIJ (n/1.oN,( fpr" j . /• IAAYJ (, <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 Ordi s, Rul and Reg lations, and all applicable California State Laws. Pv f <br /> Signed x <br /> Tille/Company L �' r-+' lS � Cff�nE I A'/ Y L <br /> Print NameAGLt- �+ Date <br /> DEPART'ME�NcT USE ONLY <br /> (/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS : /20 / S C Zw� <br /> WORK PLAN DATED ' D Z <br /> Date Issued <br /> Area <br /> Application Accepted By � . 3 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMfTTED CHECK # I RECD BY DATE ' PERMIT / SERVICE REQUEST # INVOICE <br /> ( 131 1 (0 A 1t4-il!)z 0.03//69 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachmentdo.,/. ., 9/27/00 <br />