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WELL Pwr—cRMIT APPLICATION FOt A SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 �ILCOPY <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 /> I Assessots <br /> WELL Location IOSU fuv' �rM+a+.l' Cross StreetC4��f_ cv t.{+�City S�vrk7vi^ ZipgS2U I Parcel# <br /> PROPERTY OwnerQIw•I C,- yr Address (050 kr}+'D�-+-�..� City Zip 9SZOI Phone# 'oh :7-64335 <br /> C-57 Contractor Fri ddress 3qq 51. -ri"i Ipt�e: City y.�Zip957SZ uc#4W6S Phone#271772- 7570) <br /> Consultant Sub Contractor ATC Assoc. Address 1117 L�,W '}B City f"fjes to Uc# Phone#2Ln 5'#f-Z2Z 1 <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE P <br /> $NEW WELL RING CPT. EOPRO HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type belc>•p) <br /> '� EL B#RING# Ofw b0�k aj O 1 JP51� [I OVER-BORE <br /> Il PRESSURE GROUT <br /> *Other: Grout Specifications: 112E'' 0011-+ .fir vT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING o HOLLOW STEM DIA.OF BOREHOLE 4_2' MULTIPLE CASINGS?0 YES ❑NO WELL CASING DIA NA <br /> a EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS AA TYPE OF CASING: O STEEL I]PVC ]]OTHER: NA <br /> a VAPOR a MUD ROTARY EPTH OF GROUT SEAL SO TREMIE TYPE TO BE USED: GAUGERS ,$HOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: N4--k C-e-+N`n 4'f <br /> o OTHER: (1 OTHER APPROX.BORING DEPTH SCJ' o BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NA (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 Ordinances, Rules and Regulations, and all applicable California State Laws. A <br /> Signed lt.M/rt- Q21�Y Title/Company 1"'f t L. 45<snC t 0. 5 +I�� <br /> L.� <br /> Print Name �•�-G-h�- ` `O Date 111-2-0(01 <br /> QLPARTMMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �lz/� '�/cy✓� '� S� <br /> WORK PLAN DATED: j <br /> Application Accepted By ' Date Issued /Z7. Area <br /> Grout Inspection By Date O Final Inspection By�:. CCCC _ _Date <br /> Destruction Inspection By Date _ ,) <br /> COMMENTS l CONOrrIONS: A— 19"� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />