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WELL PERMIT APPLICATION FU`RM SITE. a <br /> _ _ MITIGATION ' <br /> .�wU+ i 'f <br /> _ <br /> .�.SAN .IOAQUfN COUNTY PUTH D VISION (PHS"EHD)VICES Y N <br /> ENVIRONMENTAL HE <br /> A _ 304 E. Weber, Third Floor, Stockton: CA, 95202 <br /> C. (209) 468'-3449 <br /> NON REFiJ1VDABLE PERNFIT EXPIRES t YEAR 49-M!]A7!BSI <br /> !Appr'ication is hereby made to San joaquiri County for a permitsonoa�ct andlorof San Joaquininstalaunty P.blit Health Services,Environmental Health the work deSW1303-,m i his appu,,..cn is made in SDi'sian.�San <br /> .Joaquin County DevelopmentTitie,Chapier 9-1115.3 and the Asseswes ?i?�d�' <br /> 1 S Zap Pan i# CA i <br /> WELL Location f�o� 0G1.c1 ,' _Cross Street <br /> City <br /> pp Vt zlp�7Phon' 2 ��Q <br /> PROPERTY Owner W Address 1 0� Lq City rl7' -7�74 <br /> o,SCc�- •� On�, - <br /> C-57 Contractor- <br /> 15:L 1i 6cM o� p ,17 Phan#! 7"LOCI <br /> Consultand Sub Contractor <br /> gra r'` Address S l�c�✓ Clty � <br /> Range Section <br /> GIS Coordinates:X Y Township <br /> WORK TO BE PERFORMED: ��jI=STRUCTION(choose type below) <br /> I]NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH.IfAND-AUGER,OTHER') ^ 9OVER-3CRE <br /> []SOIL BORING# �RESSURE GRCUT <br /> Q WELL# Grout Specifications: <br /> 'Other. y <br /> COMMENTS: <br /> .TyPEY OF yyEl�L 1NSTALtATI6N TYPE CONSTRuc-noN SPEgincAnoN5 ' xQ WELL CASING DIA: <br /> HOLLOW STEM DIA.OF BOREi OLE MULTIPLE CASINGS. �YES (i <br /> MONITORING II TYPE OF CASING: 1]STEEL q PVC U OTHER <br /> []E MIAC71ON <br /> AIR I lAMNEE3�IDRiVEN CASING TE iICKNESS � TRl�A�E TYPE 70 t3E USED: 1]AUGERS 13 HGSE <br /> 0 VAPOR l3 MUD ROTARY <br /> DEPTH OF GROUT SEAT- <br /> R <br /> AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: LI Yes [IN, <br /> (NOTE: MAXIMUM FREE-PAu-13EPTH IS 30')' <br /> a SCIL BORING I]HAND AUGER GROUT SPECIFiCA7iaNS: U BOLTED TRAFFIC BOX Or STOVE PIPE <br /> 11 OTHER OT}iER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (it YES,list specifications here): <br /> 'COMMElHTS: I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT�PNSP C� NS <br /> CAL1 THE UNIT 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REiLIiR <br /> I hereby certify that I have prepared this application and that the work will tae done in accordance with San Joaquin <br /> County OrdinancesRules an egula#ions, and all applicable California State Laws.- <br /> , <br /> Title/Company <br /> Signed x <br /> Print Name <br /> I ��� Irate . O k,3 0/ <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT EV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> I. O° .` 'tea_____-�_ <br /> �. Date Issued [/C <br /> Application Accepted By Final inspection Py <br /> �� � <br /> Grout Inspection By <br /> ate t <br /> Destruction inspection By <br /> COMMENTS 1 CONIDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES F INFO AMOI!NT RE=MITTED CHECK# REC'D 6Y DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 7 <br /> �02' :; ;,�a n-©'� J � D 2 � 4/27/00 <br /> C_57 WC _WAIVER G-57.Letter of Autha io t ign permit--:—i=ncroachrnent doc <br />