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av <br /> I WELL PERMIT APPLICATION FORM I <br /> { SAN .fOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIV ION (PHS-EHD)" UNIT IV <br /> ' <br /> 304 E. Weber, Third Floor; Stoc�ton, CA., 95202 <br /> (209) 468-344 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 Developmeht Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. � <br /> n�, �1 1 Assessor's <br /> WELL Lacationt srE.�! �(1S• E` S�- Cross,/Street moi.`' �i 5i, city <br /> Zip Parcel# <br /> PROPERTY Owner Or L�IJ Address 7 N. 6 a7 o City Zip SZDZPh...# 4q <br />� + l <br /> � Addres " lc#72b%4hone# -I-YtODC-57 Contractor _)n L <br /> Consultant/sub Contractor f T/ nZfL2 r�Address City (699f DZZ Phone# fo -`/710 <br /> f <br /> G15 ordinates:X 'Y Township #' Ran - Section <br /> rtm e it �, PLS 7-O i 3--j,160S <br /> WORK T�ORME <br /> []NEIN WELL/BORING(OPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below <br /> E [I SOIL BORING# XOVER-BORE V <br /> III ELL# ri s- <br /> *Other: 'pec fications: <br /> COMMENTS: <br /> II „l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIPICATIONS <br /> p MONITORING []HOLLOW STEM DIA.OF BOREHOLE N ULTIPLE CASINGS?0 YES n NO WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS r; TYPE OF CASING: 0 STEEL n PVC. []OTHER: <br /> []VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [)AUGERS 1]HOSE <br /> []AIR SPARGE aI PUSH POINT GROUT SEAL PUMPED:, n Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 3D') <br /> ©SOIL BORING q HAND AUGER GROUT SPECIFICATIONS: <br /> u t <br /> 11 OTHER:- n OTHER APPROX.BORING DEPTH__[]BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOS D7 (If YES,list specifications here): <br /> 'COMMENTS: <br /> li <br /> BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT <br /> NOTE: OFFSITE Q S. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOUR91IN ADVANCE FOR ALL REQUIRED INSPECTIONS. s <br /> I hereby certify that 1 have prepared this application and that the wok will be done in accordance with San Joaquin <br /> County Ord[ antes, (Rules and Regulations,and all applicable Callfc rnia/,S/tate Laws. <br /> Signed x Title/Campan <br /> Print Name i Date <br /> DEPARTMENTS USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 160.5 5 <br /> WORK PLAN DATED:i 3 -& —0 <br /> Application Accepted By Date issued <br /> S ZZ Areae <br /> Grout Inspection By pate Final Inspection By <br /> VA <br /> Nor- <br /> Destruction Inspection By j to <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D' BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 0 <br /> C-57 WC -WEAVER G57 Letter of Authorization to,sign permit EncrancFtment dac 9/27/00 <br /> 10 30Vd N00-ij HJ.AIJ EEbE89b60Z . " 99't,T T00Z/L0/£0 <br />