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.. <br /> � ) r`` <br /> WELL PERMIT APPLICATION FO1�M SITE <br /> NEC E-MVE� MITIGATION <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> AUG 7 Zppt <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 <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 /> city <br /> CE_ _�a_(/ p Assessor's <br /> WELL Location ��� �(„�-`�(',/��lu/ /��(�� Crass S/treet ��s�'� Ci �' Zi Parcel# <br /> PROPERTY Owner <br /> -U&A ye/--!i/aL j4 dress //Dn CZ a'QVU.914t�a CityZip�Phone# <br /> C-57 Contractor 01I�Ao /Y!'6 YiG{�L/ Address.63I0�. Z-1Y TJ'�/W��ity //JJ Zip Lic /?Phoneg5�� 1 <br /> Consultant/Sub Contractor f-1 ��@ Address ! ,�Q(J) Y�1LOityy -ic#Phone# /UD <br /> GIS Coordinates:X ;Y ,.Township Range Section - <br /> T „ <br /> WORK TO BE PERFORMED: <br /> - <br /> p NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) XESTRUCTION(choose type below) <br /> 0 SOIL BORING# :{ VER-BORE <br /> I7 WELL# ! / RESSURE GROUT <br /> ''Other: Grout Specifications: 'T <br /> COMMENTS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING o HOLLOW STEM DIA.OFBOREHOLE MULTIPLE CASINGS?o YES o NO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMM6JDRIVEN CASING THICKNESS TYPE OF CASING O STEEL 11 PVC []OTHER: <br /> VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> -A1IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ifY56,list specifications here): <br /> 'COMMENTS: `/ C IQ-S [ vw V <br /> V e11.9 RV <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 a�nd'Regulations, and all applicable California State Laws. / <br /> Signed v�(.(ir -OL�LC/7� Title/Company-04(ec <br /> Print Name Date 7� <br /> DEPARTMENT USE <br /> ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /Off/) ff CtO r <br /> WORK PLAN DATED: <br /> Application Accepted By 'Date Issued Area <br /> Grout Inspection By Final Inspection By Date <br /> Destruction Inspection By Date - <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# PA ' <br /> PE CODES FEE INFO AMOUNTIREMITTED CHECK# I RECD BY DATEJ PERMIT/SERVICE REQUEST# INVOICE <br /> iso 3 �0r3Z <br /> C-57_ W(;--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />