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4 77.0 <br /> WELL PERMIT APPLICATION FORM <br /> • MITIGATION <br /> /A SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> tj 1'' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, StocCton, CA., 95202 <br /> (209) 468-344 <br /> NDN-REF <br /> UNDASLE PERM EXPIRES 1 YEAR FROM DATE ISSUED 0/� <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 8-1115 3 and the Standards of San Joaquin Gmunty Public Health Seances Environmental Health Division <br /> Assessor's <br /> WELL LacatronC S Cross07 444 <br /> �/Street s 30151, Ity SFrV uy —Zip Parcel# <br /> PROPERTY Owner ti�vh� Address i�/Al > City Zip SZD2-Phone# <br /> C-57 Contractor 1 7�pC. Address C1 Zip Lic#72p�4hone# ^I <br /> Consultant 1 Sub Contractordress C�ty�l [l�c# aZZ Phoria# J�7�� <br /> GIS ordinates_X Y ,Township Rang <br /> ngfr Son <br /> Y�l� rsn- !(COS S ell Cyst <br /> WORK T BE PERFDF2dAE DESTRUCTION (choose type below " <br /> 11 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') COVER-BORE <br /> i1 SOIL BORING# <br /> Nk�VELL# <br /> 'Other Spec ficatians <br /> COMMENTS <br /> TYPE OF WELL INSTA LATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING []HOLLOW STEM DIA OF BOREHOLE ULTIPLE CASINGS-[]YES q NO WELL CASING DIA <br /> [1 EXTRACTION AIR HAMMER/DRIVEN GASW G THICKNESS TYPE=OF CASING (]STEEL n PVC [j OTHER <br /> R I1 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 1]AUGERS Il HOSE <br /> A�lSPARGE PUSH POINT GROUT SEAL PUMPED p Yes p No (NOTE MAXIMUM FREE-FALi DEPTH IS 30') <br /> [1 SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER []OTHER APPROX BORING DEPTH (]BOLTED TRAFFIC BOX or ©STOVE PIPE <br /> CONDUCTOR CASING PROPOS D7 (if YES,listspectfications hare) <br /> "COMMENTS <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN AD ANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify that I have prepared this application and that the wo k will be done in accordance with San Joaquin <br /> County Ord antes, Rules and Regulations,and all applicable Calif rnia State Laws. <br /> Signed x <br /> ,� Tltle/Compan �r���� �5� ��rG <br /> Print Mame <br /> �Yo/sem Date <br /> DEPARTMENT USE LY <br /> 5. V <br /> SITE MAP 1N UNIT 1V FILE, ADDRESS: <br /> WORK PLAN DATED: 3 'Z `� <br /> Application Accepted By <br /> Date Issued ZZ _p Area Q <br /> 6?y <br /> Grout Inspection By [?ate F�rial Inspeabon By Date <br /> Destruction Inspection By to <br /> COMMENTS 1 CONDITIONS <br /> A NTING ONLY 7AMOUN7TREMiTTED <br /> PE CODES FEE tNFO CHECK# REC'B BY DATE PERMIT 15ERV710E REQUEST# INVOICE <br /> O� r —D G+G 2-3( <br /> -57 WC��WAIVER c-57 Letter of Authorization to sign permit Encreochment doc 9/Z7/OQ <br />