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i <br /> i <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NIT VT10N <br /> U <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT' TV <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468.3449 <br /> NO114tEFUNDAHLE PERMIT lRIFRES 1 YEAR FROM DATE-SUED <br /> Applir.0m is hemby made to San Joaquin County for a peneit to construd endbr install ft work described. This appkation is maJo In c=v1anwvAv%$an <br /> Joaquin County Devetopment Tide,Chapter Xi 115.3 and the ShrKk rds of$sn Joaquin County Public Health Senriass.Envk nmenial Haviith Ch4slort. <br /> WELL Lm=tlon 14W N El D3m:b St. Cross Street L1nd9W , Clty Sbxkbm mo �Parmcemm <br /> PROPMMOwner JLe�E Addnwe" N- EL D3mr-b St. -City-2919m— zip:'95202 Prone#209/94 _. <br /> Car contractor--fin address 23S i9m Dr- c r�0 do zia ��c 512�68�t, 209/465- M 2. <br /> ConoWtent/Sub Contractor s Addy ' E- _ - City-•�9 -fie#, Phone# / <br /> GIS C.oardinatw X .Y Township TiN Range RGE Section 20 <br /> MMKTO BE PEREali IRD: <br /> a NEW WELL 1 BORIN 0(CPT,GEOPROSE.HYDROPUNCH,H/WD-AUGER.OTHER') $DESTRUCTION(dwose We be1mv) <br /> Q SOIL BORING# 13 OVER-BORE <br /> a WELL#1 K#P 4Bmboni� S�uE�ry ;KPRES&M GOUT <br /> *Other. ut 5pecMtatiorw. <br /> COMMENTS. At <br /> T_1[PE OF WELL INSTALLATIO�TYPE SPECIE CA „ <br /> MMONiTORiNG U HOLLOW STEM DIA.OF BOREHOLE- MULTIPLE CASINGS?a YES M NO WELL CASING DIAL=3/4' <br /> p EXTRACTION R AIR HAMMER/DRIVEN CASING TH1 4NESS .35'� TYPE OF CASING: 1)STEEL YI PVC II OTHER:- <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL - 4'_ TREMIE WPE TO SE USED: p AUGEM II HOSE <br /> p Adlt SPARGE itPUSH POINT GOUT SEAL PUMPED: p Yes U Na (NOTE: MAXIMUM FREE-FALL DEPTH 113301 <br /> U SOIL BORING Q HAND AUGER GROUT SPECtFICAMONS: ViAl G=t - 1$b3rjit- <br /> a OTH1!R _0 OTHER „-„ APPROX.BORING DEPTH K' E HUED TRAFFIC BOX or.'0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDf(if YES.Rst specifications hone): <br /> *COMMENTS. i me Abe the type of w ill try be moved and 2i7e[ICY7[ d bx=r¢a4 <br /> _. <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 /> 1 hereby eerUfy that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> I <br /> County Ordinances, and-Regulations, and all applicable CallPorrtia State Laws <br /> Signed:. Tltle/Campany S SA0o R <br /> Print T S s—= s Cr- w Dale [Z -1-0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> area eQ�-- <br /> Applicatfan accepted sy '.' Oats issued <br /> Grout IMeedon By Date Final Inspection By Date_,__,,,` <br /> Destruction Inspection By Date <br /> COMMENT51 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> Arm <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUE=ST# INV=E <br /> az D Lam- 1 to avz�z-7 3 <br /> C-57 WC -WAIVER G-57 Letterof Authorization to sign pert+nit Encroachment dor+ 9/27100 <br />