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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH dIVISION (PHS-EHD) <br /> 304 E. Weber, Thlyd Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> N N•REF NDABLE PERMITT'E ISSUED <br /> Application is herebymade to San Joaquin County for a permit to construct and/or install the work described. This application Is r lade in ccntpllance with Sar. <br /> :oaquin County Development i Itis,Chapter 5-1116.3 and t..e Standards of San Joaquin County Public Health.Services.Enviror rental <br /> H a sDivision. <br /> AsseWELLLocatlorr_9705 <br /> Cross Street 4Gr Clty ttY�—Zips-Farces#! <br /> ,� City� �ZPg�9 Phoned �(6( <br /> PROPERTY OwnerL I/L;iI tlti —P.ddress - er�nc Cry <br /> _Adaressa? sryl sr--CItyZipJ.>�-L:c#Sr2P"•arfe {. - Ul-2 <br /> CS7 Contractor QQ <br /> �rn,n��7im Address c/ �� C1[y�CL•31�u= Phoned 8.743~S __ <br /> Conaultani i Sub Contractor <br /> cis Coorcinates:X___. <br /> Township Range Sectlor <br /> W RKT BEP _ Q DESTRUCTIOti(choose type below) <br /> •pj WE I BCRIPIG i, EOPROBE,HYDROPUNCH,NAND-AUGµR,OTHER') a CL'ER.SCRF- <br /> S01L BORING p f# I 0 PRESSURE GROUT <br /> lI WELL N <br /> Grout Sper;rications: <br /> •Other. <br /> COMMENTS: <br /> TYPE DF WELL INSTALLATION TYPE CQNSTRUCTION SPECIFICATIONS <br /> MONITORING �OLLCW STEM DIA,OF BOREHOLE_ is! MULTIPLE CAS.NGS7 0 YES NOYlF1 L CASING DIA: <br /> (]EYTRACTION [;AIR HAMMERDRIVEN CASING THICKNESS <br /> TYPE OF CASING: a STEEL d PVC E OTHER: <br /> (]VAPOR [j MUD ROTARY DEPTH OF GROUT SEAL 30 : TREMIE TY°E TO BE USED ,AUGERS U H:tSE <br /> ;r�s <br /> AIP SPARGE []BUSH POINT GROUT SEALPUVPED: g�fes 0�o (NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING Q HAND AUGER GROUT SPECIFICATIONS: / <br /> APPROX.BORING DEPTH 30 - o BOLTED TRAFF!C BOX or Q STOP=PIPE <br /> p OTF:ER:_ E OTHER <br /> CONDUCTOR CASING PROPOSED? ('(YE3,lis:specillcatiens 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 INSPECTiONL" <br /> I her certl that 1 ave prepared this application and that the work will be done in accordance with San Joff <br /> County Ord' n a, es and Regulations, and all applicable Callfarnia State Laws. i�4 <br /> Signed x Tit.e/Company of <br /> _ Date 10t <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7� A2 <br /> WORK PLAN DATED: 1 6 c'C> <br /> �J O <br /> App!Iration Accepted BY Data Issued Area r w� Date�Q <br /> Croat inspection By M LACE data Z- Final Inspemlon By <br /> Destrt.ction lrspecticn By Date <br /> COMMENTS ICON DITIONS: <br /> ACCOUNTING 10 A1D�f <br /> PE CODES FEE INFO AMOUNT RENIMED CHECKS RECD BY DATE PERMIT(SERVICE R€QUE5T ax INVOICE <br /> r_r^'7 %Air- -WATVFR C-57 Letter of Authorization to sign pe-mit Encroachment doc_ 9127/03 <br />