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It <br /> UT <br /> WEL&PERMIT A'PP'LICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 O N <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 /> WELL Location 2-1,02) �.0un�2g G4� U\ Cross Street�n.v.�`In DWEcity u 'tQ�_zip IT24iq arcel#ofs <br /> PROPERTY Owner�6�.c 1Oe.OP4 �Adddress1`� �], ��I` rtrLtW\yAv� KJ!City ,5 E4 Zip '-I$$3 Phone# <br /> _5 -9q %!j3- <br /> Ch7 ConVac[or G _� Address_I�ppv�rf�_� Ciry to i Zip lYo Lic# bT-phone#X25 JIJ'$BGp <br /> 00 (IN1 (1I � R+a&zbj C c1, <br /> Consultant/Sub Contractor_ (D Orbe ar`c7r`owaY 6v—Address 3Dfl IU'�to�d''OD City �.led� Lic# s�tljb Phone# 116—d1ol—ogo(� <br /> GIs Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> JEW WELL/BORING(CPT.GEOPROBE,H ROP NCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING 0 OVER-BORE <br /> q� B WELL# o PRESSURE GROUT <br /> *Other: Df S4 locftfn( Grout Specifications: tJus.t cell-,n. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS OK <br /> NO MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ` -S r' MULTIPLE CASINGS?0 YES O NO W ELL CASING DIA:Q114,` <br /> 11 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIS TYPE OF CASING: []STEEL, ❑PVC BOTHER: !J R <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL Z.Or TREMIE TYPE TO BE USEO:XAUGERS 0 HOSE <br /> B AIR SPARGE ,PUSH POINT GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:_fl�eAk eexnY\.} <br /> O OTHER:___XOTHERDirt1k APPROX.BORING DEPTH 20 r o BOLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? <br /> _RL_(if YES,list 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 Ordinan Rule and Regulations, and all applicable California State Laws.`` <br /> Signed x 1z Tllle/Company C.iox Sci lrC, <br /> PrintName 9j2tAlt S,,\Vq Date 1/1-1101 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: � 63 (p.Gtr 4 *6144s¢dC fltop <br /> WORK PLAN DATED: -U/ <br /> Application Accepted By Dale Issued 2 G Area Obi-4 <br /> Gnxrt Inspection By Date Final Inspection By e <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: 64 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CH CK# R 'D BY *1D)AjEjPERMIT f SERVICE REQUEST# INVOICE <br /> SO C-57_ WL_-WAIVER_ C-57 Leiter of Authorization to s _Encroachment doc_ 9/27/00 <br /> 60 30vd 2100_13 H13I�i ££4£89060Z T£ :ET 0007/70/ZT <br />