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SITE <br /> wELLPERMIT APPLICATION MITIGATION <br /> U''1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT N <br /> HEALTH DIVISION (P}IS-END) <br /> ENVIRONMENTAL Stockton, CA., 95202 <br /> 304 E.Weber, Third Floor, <br /> - (209) 458-3449 <br /> R FROM DATE ISSUED licatien is made in compliance""San <br /> NON-REFUNDABLE PERMfT EXPIRES 1 YEA Assessors y D ,dl <br /> rnnstruct and/or install the work described• This app <br /> for a permit 10 Joaquin County Public Health Services,Ew,ronmental Health Division. <br /> b made to San Joaquin County LP Parcel# r1S 7=--- <br /> Aopllcation is here Y Cha ter°x11'15.3 and the Standards of San Joaq 6 SG 3 3 y <br /> l <br /> Joaquin County Development iIUe. p Gross Street C- �r' v) City O�� p Phone# <br /> LahQ, City1 q G� <br /> WF;L Location - -Ta c In L17Phon �) J 3"Sd <br /> nAn S`c� Address Zp01(+�ZLidF�S <br /> PROPERTY Ownerh' Il -'}Or.-'e P Gly r1 � I UV 6 <br /> 1 Address U � �,��J,,nUc �,(, Phcne# <br /> 2 5 7 V 5 ` City�� <br /> C_57 Contractor y-tt-rG —Address <br /> Section_--- <br /> . Consultant I Sub Contractor Range-_ --- <br /> Townships----- <br /> Y_��_ chaos,type betow) <br /> GIS Coordinates:X�� U GEST RUCTION(OVER-BORE <br /> yYDROPUNCH.HAND*AUGER•OTHE'r) PRESSURE GROUT <br /> WORK TO BE PERFORMED:?.GEOPROBE,. r in' _ <br /> EW WELL!BORING( OIL BORING <br /> 0 WELL# Grout Specifications: <br /> -Other. �_ <br /> COMMENTS: <br /> CONSTRUCTION SPECIFICATIONS WELL CASIN <br /> INSTALLATION TYPE tt MULTIPLE CASINGS?Q YES NO OTHER: <br /> TYPES F`��LL -- DIA OF BOREHOLE �E OF CASING: Q STE �C p <br /> 0 MONITORING R HOLLOW STEM Hcc- <br /> Ex7FtAC710N ❑AIR HAMMEPMRIVEN CASING THICKNESS /1 - EMIE TYPE TO BE USED: ❑AUG'rRS <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL_- <br /> 0 <br /> VAPOR GROUT SEAL PUMPED: 0''l° (NOTE: MUM FREE•�FIALL DEPTH IS 30^, <br /> USH POINT ave t cil/U>� rr d-U <br /> 0 AIR SPARGE GROUT SPECIFICATIONS `ly STOV,{==�= <br /> OIL BORING ❑HAND AUGER L L BOLTED TRAFFIC BOX ar � <br /> D OT}1ER_�— APPROX BORING DEPTH if YES,list specfi¢acns here): <br /> OTHER: CONDUCTOR CASING PROPOSED?iI <br /> -COMMENTS: <br /> ESS OR <br /> CRO <br /> NOTE: OFFSITE <br /> BO <br /> RINGS <br /> wORRKaINGI HOURSRE CIN ADVAtiC�OR ALL SQUIRED INSPECTIONS. <br /> CALL THE <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, <br /> and all applicable California State Laws <br /> TillelCompanY <br /> Signed x Dole <br /> f I U I �� <br /> print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: l Ic1l p r Area LbP <br /> „ I <br /> Date Issued Date=/ Z- 20 <br /> Application Accepted By Date - 7 0 I Final Inspection BY <br /> Grout Inspection ey Date <br /> Destruction InspeUien By <br /> COMMENTS I CONDITIONS: _ <br /> ACCOUNTINGONLY: AID# PERMTrISERVICEREQUESTS ( (NVD♦�" <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK Y RECD BY DATE <br /> 9/ <br /> C-57 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br />