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0.1-R V-IF-G-wl-it-INV'-RA I L <br /> WELL PERMIT APPLICATION FORM SITE <br /> ' <br /> S &w* MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT A <br /> C ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> . 1 h? tV,%M6toa 5 ° 304 E. Weber, Third Floor, Stockton, GA., 95202 <br /> Am, irmILS If Pict- (209) 468-3449 O>-r <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> C'o w-Y <br /> Application is hereby made to San Joaquin County for a permit to construct andior Install the work descnbed This application is made m compliance with San <br /> Joaquin County Development Title Chapter 9-1715 3 and the Standards of San Joaquin County Public Health Services Environmental:Health Division <br /> Assessor's <br /> WELL Location +(�b fll � Cross Street {�?its�c'�+ _City— Zp Parcel# Grdlf . ^ <br /> PROPERTY Owner , Address,�L/.y Ikzelz-a 4Lff --CityS&L,4- _---zip }Phone#ycy c&e 36V <br /> C-57 Contractor(.lJc rLcr o���►j�hL ----Address I`�',x 7r���' C ty ,�r'l��3 ztp � 7 Lic# 7/c �7Phone# '7 �r fY <br /> Consultant 1 Sub Contractor GL'er,ts�+ � - � »Address l3 f=� �si$-i_Cityic#^S Phone# �30 �G�S.xo <br /> GIS Coordinates X ,Y Township Range Section— <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a DESTRUCTION(choose type beioti%) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# fl'1tri ;Z A9 a PRESSURE GROUT <br /> "Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 'J -HOLLOW STEM DIA OF BOREHOLE kdmlN MULTIPLE CASINGS?lj YES gNO WELL CASINO nIA, t�cjl <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Sial t4 TYPE OF CASING 0 STE€L '$PVC D OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL =b / uTF21=MIE TYPE TO Bc USED AUGERS rs`CSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED EyYes 0 No tNOTE. MAXIMUM FREE-FALL DET''H IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS -- -_ <br /> [}OTHER 0 OTHER _ APPROX.BORING DEPTH-1k-A r'f�_-_[�BOLTED TRAFFIC BOX or [}STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,Inst specifications here) <br /> *COMMENTS -�---- - <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 that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordin ce Rules and Regulations, and all applicable California State Laws <br /> Signed x / Title/Company — <br /> Print Name V'�,�P-• �' �'7`�'r�'e _Date �"SCJ- 2�✓� - -T <br /> -DEPARTMENT USE ONLY( <br /> SITE MAP IN UNIT IV FILE, ADDR SS GQ <br /> WORK PLAN DATED: /Z/0 4 <br /> Application Accepted By --_— Date IssuedMfi <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS C _01- CC" <br /> ACCOUNTING ONLY AID# FAQff <br /> PE CODES FEE INFO AMOUNT F?EMITTED CHECKS REC'D BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> 49Z58� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />