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A ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ` <br /> (209) 468-3449 'v\ <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 /> r1.uE. I�,,,,,y Assessor's <br /> WELL Location 4904- W. &d¢xl w/r1 Cross Street ¢..,e.o City SToc s ca Zip 95 zp, Parcel# 16b-ozo-I'I <br /> - <br /> PROPERTY Owner ee top,� Fce.�Nf 6L, 3[co City Y K1N��z�lCI Zip4o56�Phone# (ASg� 543-21, <br /> C-57 Contractor 6jALFV fX4M4, Address 23-65 Wile'WA-YK city✓&C1.&>Eiq r Q Ic#S&uig one#?P9Y E/G <br /> C1F_oMxa-< <br /> Consultant/Sub Contractor CoNSe..rn.MT'; SNc- AddressZ444. Msi� Lr, Sre zls City Fe".ao Lic#BE- 115 Phone# 559 2-4-t535 <br /> GIS Coordinates:X 3-1.531y .Y -1 ml .als4 .Township T t Range 11 (o E. Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> p SOIL BORING# -$OVER-BORE <br /> $WELL#MrdS-A S- �, 0PRESSURE GROUT <br /> *Other: Grout Specifications: Z saa.Ks Aw- -o I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES NO WELL CASING DIA_ <br /> o EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS -cA. 4u TYPE OF CASING: O STEEL XPVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4' FST TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> [I AIR SPARGE aPUSH POINT GROUTSEALPUMPED: (IYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: p OTHER APPROX.BORING DEPTH Zia FEET p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? rlo. (if YES,list specifications here): <br /> *COMMENTS: SEE.. w c. �e <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 tha V repa his application and that the work will be done in accordance with San Joaquin <br /> County Ordinan d Re ons, and all applicable California State Laws. <br /> Signed x - \ Title/CompanyEaar-+n,TR1�C Mot�l-,�+t'1-';i =� <br /> Print Namee�wr a-o ��+Ku--D�1 Date Z <br /> DEPARTMENT UUS``�EE ONLY <br /> / r <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 46 / C,� 44-1 � Shu �CyQU-&p <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued /0'/9`O / x -Area Ovjfy <br /> Grout Inspection By Date Final Inspection B1 la n =a 1 jai-� Date ??4•p s <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# _ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 290 <br /> WD bo• 5D41 2 0 <br /> C-57_ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/0( <br />