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F J8f' 3r'2abi7 11: 1b El�4hS 4�; r it- IH rLLlutk <br /> WELL$PTE'RMIT APPLICATION FO' M SITE <br /> SAN JOAQUIN.COUNTY PUBLIC HEALTH SERVICES MITIGATION ' <br /> AUG 2 8 lA IVIRONMENTAL HEALTH DIVISION (PSIS-EHD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton,4"CA., 95202 <br /> ENVIPGNM,iriv i hEALTH (209) 468-3449 <br /> PERMIT/SERVICES <br /> NON-REFUNlDAeLE PERMTT EXPIPES 1 YEAR FROM A7 ISS ED <br /> ;plication is hereby made to San Joaouin County for a permit to wristruc-t andlor instalt the nark desCribeL+- Th;s 3gp(i=tjort is made in compliance wi?h San <br /> :aauin County DevelopmentTLLle,Chapter 9-1115-3 and the Standards of San Jeaquir,C onty Putiiic Health Services,Environmental Heafth Oiviaion, <br /> _62.�I , ���-Q, A5525Sr71s <br /> � l Q E <br /> 'ELL Lacaticn �e� - Lcross�s}treet <br /> ROPERTYOwner„ o c2M2(, Address 9 <br /> 5Lf�- nciry City�_- -�kiu-��->r k-zip Farces# tS `315 — I�o <br /> zipq Phone# <br /> cs1r <br /> -57 Contractor)J`l<kx\1 �dl 11.1 Address IPO 1�0 zip_qV_1_Uc#_j�Ptionex!V&Z?7 a <br /> erwultant l Sub Contractor l�YlG �tUtl(G[>Y11e rt ddrass�1E 1 t]+i L. S}{t��#'City., _ a _11c.` S� Phone#��$$,3 L1'IS�� l <br /> IS Caordinatas:X Y Tewnshlp Range Section I <br />'r ORK TO.. eRFORME13- �! <br /> I <br /> *IE'rVELL' CRING(CPT.GEOPRCSE.i-tYCRr PUNCH,HANG-AUGER OTHER`, Q DESTRUCTION(choose type hslMv) <br /> 11 SOIL 8CRING M l]OVER-8cRE <br /> ©WEt.L# [VLI+� �, �` - -- _ - --. D PRESSURE GROUT <br /> lther_ GROUT SPEC[FiCATiON <br /> rJMMENT S: <br /> (PS OF WELL INSTALLATION TYFE CONSTRUCTION$PFCIFiCATIONS } <br /> IAGN� ITORING {HOLLOW STENT ❑:A.OF SCREHOLE 1�9 LAv— MULTIPLE CASINGS? Ij YES )640 WEL-LCASING OiAl_(-� <br /> cXTn^ACTION Q AIR HA,MNIFR/CRIVEN CASING THICKNE55S.0-40---rYPIS GF CASING. U STEEL VC 13 OTHER: . <br /> VAFOR 0 MUD ROTARY DEPTH OF GROUT SEAL Oln TR M4E TYPE TO BE U:5 V; CtGERB [yi 405 <br /> AIR SrAPGE Q i-USH PCtNT GROUT ZEAL PUMPED; C Yes Q ho [NOTE: MAXIMUM FREE-F�L DEPTH �S 3C3') <br /> $CIL BORING [3 HANG.AUGER OsROJJT$r=_CIPICATION <br /> OTHER: lj OTIHER APPROX-BORING DEPTH DLT ED 1'RAFF}C SCX or' Q STOVE PIPE <br /> CONDUCTCR C'✓,SINC F 1ZOPC$EO^ PJ d if YES,list specificaticrs here): <br /> 0MMENT5: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin <br /> aunty Ordinances, State Laws, and Rules and Regulations of the Sart Joaquin County. <br /> CALL THE UNIT iv INSPECTOR 8 ORKING HRS I[V, AJDVANCE FOR ALL REQUIRED INSPECTIONS <br /> - +�-" -TitleiCompany W r1q� � 1f'11�► fDC\ [gym.' Cwt � ,t`t2iLC5 _ <br /> int Name <br /> SITE MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED " <br /> PART 1ZNT JUSE ONLY <br /> );)Ii(ation Accepted sy w Date Issued": Areas <br /> wGIt Inspection Sy Date Fine(fnspecffen By Date <br /> tstR;c:ion Inspection ey3 <br /> S OM'�1EHT5!CONd ONS: ' t L <br /> rs. <br /> *nti <br /> 4CC0UNT;NG ONLY: Alar j <br /> 'E COdltiS FEE INFO AMOUNT REMITTED CHECK E R 'D Y i DAT PERMIT/SERVICE REQUEST Ir INVOICE <br /> G-57_ WGtWAZVER C-57 Letter of Authorize on t gn permit Encroachment doc 7/17I00 <br /> I i1 <br /> M <br />