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0912812001 12 13 2094683433 FIFTH FLOOR + PAGE Sts <br /> WELL PERMIT APPLICATIONF6RM <br /> _ SITE <br /> CRVMITIGATION <br /> JOAQUIN COUNTY PUBLIC HEALTH SICES <br /> ENVIRONMENTAL HEALTH DIVISION (PH -EH©) UNIT IV <br /> SES' 2 0 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 A ; <br /> (209) 468-3449 <br /> NON-REFUNR613LE PERUff EXPIRES I YEAR FROM QA_T_L ISSUED <br /> Appliml n� `made to San Jaaqutn County For a pesmlt to comtruct armor install ft work desc 1md This applh=do t ts made in ccrr61WAae With Sari <br /> loarqum County Demlopmd Title,Chapter 41115 3 and the Standards of San Joaqum County Publk Health Services,Enmronmentaf Health Dmsion <br /> f; Assessor`s <br /> WELL_Locatlon� Dl{ V—' &t%e g _Cross_,Cross Stn�et Cif I Trp Q a7 Parcel I gfl -260 .27 <br /> PROPERTY owner A. A' /cAMAddress I.F7*4104w4oe At.. Cdy o e- Zigp9tt0q Phan w�m?5,3,�tnv <br /> C-67 z;cntrec#orGG4� 1,�� �Addmss_�'.G_ Cly Loo. rip uck-23 Phone# <br /> Consultant/ Ca nnM.kc�/ob&# ! S7Phone# I s3dv <br /> GIs Coordfnges X Y. Township -�2/�'-- _--Range I Section .Z1 <br /> WORDS TO BE PERFORMED <br /> a NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HANG-AUGER,OTHER-) DESTRUCTION(I oosa type below) <br /> a SOIL BORING# Q OVER-BORE <br /> Q WELL 0jW eA.12_-- ESSURE GROUT <br /> *Other Gran Specaficatiorts ?.A mWi A&W <br /> COMMENTS. ; - - <br /> r <br /> TYPE OF WELL INSTALLATION TYPE COMTRCCTION SPECIFICATIONS. <br /> glWONITORING a llOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASIf4GS?17 YES 11 NO WELL CASING DA <br /> RACTION a A)R KWMER/DRIVEN CASING THICKNESS_ _ _ _ _TYPE OFC SING U STEEL 0 PVC ItIOTHER <br /> 13 VAPOR a MUD ROTARY DEPTH OF GROUT SEA. TRF IE TYPE TO BE USED 0 AUGERS 0 HOST= <br /> J3 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED 0 Yes a No. (NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING {j HAND AUGER GROUT SPECIMCATIONS <br /> 0 G 114ER Q OTHER APPROX BORNG DEPTH 0�BOLTED TRAFFIC BOX o� iJ STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ;a YES,fist speed-Wallons here) <br /> •COMMENTS• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENC OACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FO ALL REQUIRED INSPECTIONS. <br /> I hereby certify that i have prepared this application and that the work will be doIa in accordance with!San Joaquin <br /> County Ordin es, Rules and Regulat(ons,and all applicable Calltornla State L�"' <br /> �j <br /> Print Narne �dri _f_�G_n U2l-le _}ate - Ge <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: i J <br /> WORK PLAN DATED: —0/ <br /> -••J <br /> AppflC.2bOn ACaeptad t3y Data 155UAd r C <br /> Grout Inspect,on try Date Final lnspscilon By WSW "EVENOWEP& <br /> �Desbu&Jon Inspection 13Y Date <br /> COMMENTS f CONDITIONS. <br /> ACCOUN'TIING ONLY AID# ! <br /> PE CODES FEE INFO Amoum Remrrmo cHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> F -1 <br /> r.R7 Wr• -WATVr-O e'R1;71 o+tor of Aitthnr+rfil%^n to eenre norn+st Fnrrnnr•hr+tiartt rinr Q177/Cil} <br /> --, r <br />