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�S WELL PERMIT AP ^ <br /> PLiCATIQN �'OR`1r1 SITE <br /> 111EAl_11i <br /> f> OAQUINFCOUNTY PUBLIC HEALTH SERVICES UNIT IVTIQN <br /> ENVIRONMEtJT� HEALTH DIVISION (PHS-EHD) UNIT N <br /> 03 Obit. !�`�9hird Floor, Stockton, CA., 95292 <br /> (209) 468-3449 <br /> NON (0MED <br /> -REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED enLr <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 Sari Joaquin County Public Health Services,Environmental Health Division. <br /> HELL Location ZOO C' t�ef n3� CrJss Street Ccvv` L� <br /> Assessor's <br /> \ <br /> City S�-�����rzip SS_ �—Parcel# r62- )g)- pZ <br /> PROPERTY Owner` AQddress_ � zyX ZSS 7,A,{ City SO4-f-� —a Sip Phone# <br /> C-57 Contractor Address \Q �s 3� �' City LS �.1�1 7Up t S��I uc#�Z 0 90V Phone# q 16 7-7 )Oz <br /> onsutta ,Sub Contractor �-Q\oS''<�4 lal,�;aAddrer City 1'15 ) ILic# — Phone# 'tSZ,Z'}jjoj <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> (j NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> [j SOIL BORING# 2-08 d- Za 5+Zl O p 2 a OVER-BORE <br /> K WELL# \�$. \oG \�o a c, 2,o S j- Zo b �� a PRESSURE GROUT <br /> *Other. SR-q-1 \3� `C 41a,�.s p a a�'1 ' \vo i_ Grout Specificati ns: <br /> COMMENTS: to\i'L,�2 — a'C��c�� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING A HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES a NO WELL CASING DIA: <br /> Q EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Q PVC. j]OTHER: <br /> Q VAPOR Q MUD ROTARY DETFi i OF GROUT SEAL TREMIE TYPE TO BE USED:. U AUGERS a HOSE <br /> O AIR SPARGE j)PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> U SOIL BORING a HAND AUGER. GROUT SPECIFICATIONS: <br /> a OTHER: a OTHER APPROX.BORING DEPTH &BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list speaficiaiti ns 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 Ordina =, R es an egulations,and all applicable California State Laws. l ' <br /> Sioned x Titie]Company 1\V�} �Tr � \ J c `L d-w <br /> Priv.Name Date <br /> DFPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 81'{ C C�jan�crG1u� <br /> WORK PLAIN DATED: 27 ,7-4,r,260Z as S j w P alutzd 03 ocjFl•f 26o2 HD eond1.b&1,U <br /> ��� ji�oa 3Application Accepted By �/���l/f'lSo2� Date IssuedArea tq53 <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 REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 501 A w tq-cc, 0 i`t'7 1-1 CNT(� t2,7303 Oa 36123 <br /> C-57_ WC_-WAIVEf2_ C-57 Letter of authorization to sign permit_Encroachment doc 9/27/00 <br /> E0 ?3Gd d �� H1�I� EEbEB9t�6aZ 99 :EZ tiOGZ/BZ/Z0 <br />