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WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> Application is hereby made o San Joaquin County for aUpe toEconstruct and//or install the work described. This application is made in compliance with San <br /> Joaquin on is p EAR FROM Og7E ISSUED <br /> County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location GH-y7 AJ �S��oo 4p 61zy <br /> DSG -- /S —_dross Street 6101 x, Assessors <br /> PROPERTY Owner Lllx'GVSF Ott City 17i F zip Parcet;t <br /> !A----- - -Vt 1 i <br /> Address GVSJ •7R.r�C Ss7Ls <br /> C-57 Contractor /�" ?�I-r' City yR''HL`/ 70__e7_$35 y�Z^� <br /> Address S22s tii'2(jgt t4 /e4 �'►^'Gb tt(('� Z`P Phone# <br /> Consultant/Sub Contractor.S/4J Ed1 R-1-'y_ ",0 vsv4Z1P�_Lic#Sd�f7SPhone# 9y�G3e'7Z7L <br /> Address VOO PO <br /> S <br /> GIS Coordinates:X Y City-City 'c# Phone# 7a--Z88-22__16C) <br /> --�_,Township <br /> WORK 7p BE PERFORMED: �—RangeSection <br /> 0 NEW WELL/BORING(CPT. <br /> GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 0 SOIL BORING# ESTRUCTION <br /> "Other. WELL# type below) <br /> - OVER-R-BORE <br /> COMMENTS: GroutSPedfications: �/ ANO Car, 0 PRESSURE <br /> TYPE OF WELL INSTALLATION TYPE <br /> D MONITORING .�--- CONSTRUGTION SPECIFICATIONS <br /> HOLLOW STEM DIA.OF BOREHOLE <br /> — <br /> 0 EXTRACTION MULTIPLE CASINGS?DYES 0 NO WELL CASING DIA:_ <br /> U AIR HAMMER/DRIVEN CASING THICKNESS <br /> U VAPOR U MUD ROTARYTYPE OF CASING: U STEEL 0 PVC <br /> o AIR SPARGE 11 <br /> OF GROUT SEAL U OTHER: <br /> []PUSH POINT TR6'dlE TYPE TO BE USED: AUGERS U HOSE r <br /> SOIL BORING GROUT SEAL PUMPED: fly,, U <br /> AUGER p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> UOTHER: BOTHER <br /> U HAND GROUT SPECIFICATIONS: V <br /> � <br /> APPROX.BORING DEPTH <br /> ---___0 BOLTED TRAFFIC BOX or C <br /> 'COMMENTS: Ztt (z ,� C=ONDUCTOR CASING PROPOSED? U STOVE PIPE G <br /> 7�-(�. u (if YES,list specifications here):—_ CC <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. C <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. S <br /> I hereby certify that I have prepared this a Cation and that the work will be done in accordance with San Joaquin \ <br /> County Or�dinanc/�/¢ RR es and egulati ns,and all applicable Californiaws. <br /> la State L ! <br /> Signed L l GI' r(J <br /> Print Na <br /> --aZ/- �11 Tide/ComPany �e_6#­ /��►2.F+i}'f- jCJti C4al� l� <br /> u/Ay�J 'r• ��/ 4 � <br /> DEPARTMENT USE ONLY Date 0 9-2.0-o Z <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPliradon Accepted By--���� <br /> Grout Inspection By Date Issued 2 <br /> Date Are <br /> Destruction Inspection By Final Inspection By <br /> Dao Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PECODES FEEINFO AMOUNTREMITTED CHECKS <br /> RECD BY DATE PERMIT!SERVICE REQUEST* INVOICE <br /> a` .vz e 66- X36 6!-� <br /> 57 WC-WAIVER C-57 Letter of Authorization to si n erm 6 d 3 I <br /> 9 P. Encroachment doc_ 9/27/00 <br /> Z0 30Vd N001i H1jIj EEPE89V60Z - TZ:Ti 000Z/TI/Z1 <br />