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1 `v <br /> WELL PERMIT APPLICATION . <br /> —" "" SITE <br /> SAN JOAQU►N COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> i UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> (209) 458-3449 <br /> APP"Oshon is hereby made to San Joaquin CNO 91FUNeDABLE PERMIT EXPIRES 1 YEAR <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public described. <br /> HealtServEces <br /> County Permit to wnsbvct and/or install fhe work desrnhed. This application is made in cmpliance with San <br /> WELL Location �� (�p,rpj2 Ltth Environmental Health Division. <br /> Cross Street l� S+ Assessoes <br /> PROPERTY Owner ('� -QOM City Lo / Q���� <br /> Address PO!A ZIP <br /> U lJ,_�.=_13 <br /> �ti IilO <br /> C-57 Contractor ,1 � D city. C,_ o f _Lp fj)„T Phone# A 3 _W <br /> Address GiSO `'JO W i' n n <br /> Consultant/Sub Contracfor_�( E' City1 r <br /> GIS Coordinates:X—_ Y n UcltSSJ,l,Z Phen , d ) 6�?16(.6i <br /> Township______Range <br /> W K TO BE PERFORMED: ----___Section_ <br /> EW WELL/BC <br /> BORING(CPT,GECPROBE,HYpROPUNCH,H <br /> `,$'SOIL BORING# 2 C T D-AUGER,OTHER') <br /> WELL# r•n^S 0 DESTRUCTION(choose type below) <br /> 'Other. Q OVER-BORE <br /> COMMENTS: Grout Specifications: 11 PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE <br /> 0 MONITORING CON57RUCTION SPECIFICATIONS <br /> ❑HOLLOW STEM DIA.OF BOREHOLE 2" MULTIP <br /> 0 EXTRACTION LEc <br /> CASINGS?o YES (1 NC WELL CASING OI��� <br /> I1 AIR HAMMER/DRIVEN CASING THICKNESS <br /> 1]VAPOR O MUD ROTARY TYPE OF CASING: STEEL ❑PVC p OTHER: <br /> DEPTH OF GROUT SEAL [°n'},%L' TREMIE TYPE TO BE USED: <br /> ' (]AIR SPARGE �USH POINT GROUT SEAL PUMPED: es O AUGERS ,g-HOSE <br /> �SOII.BORING p HANG AUGER � 0 No (NOTE: MAXIMUM M FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS: rlyN, ( fUv7(awC + 6SG11c,f r/, 6) <br /> 0 OTHER: 11 OTHER APPROX.BORING DEPTH__ ri <br /> —�__ 5U O BOLTED TRAF=IC BOX or U STOVE FIFE <br /> 'COMMENTS: <br /> CONDUCTOR CASING PROPOSED?_-- (if YES,list specifications here): <br /> &`-t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinal COS, Rule Regulations, and all applicable California State Laws. <br /> ^ <br /> Signed x i/`)� //LC//�.1� Tide/Company- �YF ��20l1 <br /> Print Name_ Y'1 G I-, ./v I 1� /1�Q h f <br /> DEPARTMENT USE ONLY Dare I,/�1Ul <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: a y SP�J. apDi <br /> Application Accepted By <br /> Grout Inspection BDate Issued I L <br /> y ,N-/�.c.u:(�� Date 'Zp U/ <br /> Final Inspection By � paw LO e <br /> Destructlon Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> pAC rC��OUNCTIING ONLY: qlp# <br /> PE <br /> 1 MODE$ FEE INFO AM011NT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REgUESI R INVOICE <br /> Allthori=Aort to sign ptrmit_Encranchtrent doc_ <br /> 9/27/0( <br />