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i <br /> I ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <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 3�-P <br /> (209) 468-3449 N <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 <br /> Division—Assessors <br /> WELL Location I74I S • CrLA/� ' I ��.f� Cross Street - L( /'-YCity ZL/LCL� Zip7�/iZ66 Parcel# /�/ 7- /�a - d3 <br /> PROPERTY Ownnner}� i �L Ra..i � t7 HI�T���K—AddressJ2I l s • L6w(7,f:� > f City�T[�(K7/lr�-( Zip75Z�J/Lo Phone# 0y�o - 29�to <br /> C-57 ContractorlrQ b ( Ifs - SI Z.0 Address 9 � U �� ct-VEL Cityf�lQjT�[kZ Zip3 Lic#((,�lo( 7 Phone# " � 3/ .3-SoCU -- <br /> Consultant / Sub ContractorAN/Aluaab I.l aVifuodM+ r`+y* Address T7 4ALU 4 _Citys7bGfZ7cnJ Lic 002ZPhone# 20 <br /> GIS Coordinates: X., y., Township Range Section <br /> WORK TO BE PERFORMS <br /> 1t <br /> JEft / BORING ((CPGEOPROBE, HYDROTJ 64 yAND-AUGER, OTHER`) - a DESTRUCTION (choose <br /> type <br /> below) <br /> SOIL BORING # [��/� o _ <br /> RE <br /> W ELL # 0 PRESSURE GROUT <br /> `Other. Grout Specifications,fications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , / <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLEMULTIPLE CASINGS? 0 YES ZINO WELL CASING DIA: /Y4 <br /> 0 EXTRACTION Il AIR HAMMER/DRIVEN CASING THICKNESS 1 '�1 TYPE OF CASING: 0 STEEL l] PVC I] OTHER: A,1A <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALTOYAL P,&L?LL/ TREMIE TYPE TO BE USED: AUGERS O HOSE <br /> 0 AIR SPARGE `$[PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREALL DEPTH IS 3W) <br /> 'SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: PE-OP i LjWt> J�- •t-�71 <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH OS ' H BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?KO ( if YES, list specifications here): <br /> 11 <br /> 'COMMENTS: — T'0 " Lpeo i7 r, S )c. �Cr�t4Jk.(� I`r} LJ7-J <br /> Wow uh 14 &&1T F!20� To/ A'L 'CrH To stAxCokck6-pAbLe . <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 Ina _ s and Regulations , and all applicable California State Laws. <br /> Signed x �/I Title/CompanySTAFrc ) 4, 1Srk1VAALtk0 u/' <br /> "V) L <br /> Print Name Date (L7 — ZJ ` D I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD SS : (/06200L / 05 !.v <br /> WORK PLAN DATED : ZOO <br /> Application Accepted By Date Issued Q 0 Areaaw <br /> Grout Inspection Bectiy Date Final Inspection By <br /> Destruction Inspon By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATEPE"ISERVICEREQUEST # INVOICE <br /> 34501 s $ - 3U OOZ od8 <br /> C-57_ WCWAIVER_ C-57 Letter of Authorization to sign permi _ Encroachment doc_ 9/27/00 <br /> = <br />