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` / J <br /> . Y V <br /> FILE COPY <br /> ` ` VV LL PERMIT APPLWATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH blVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Th)rd Floor, Stockton, CA., 95202 <br /> (209) 468-3449 " <br /> rl C <br /> NON-REFUNDABLE PERMrr XPIRES 1 Y AR FROM DATE ISSUED <br /> Application is hereby made to San Jcagpin Cou,}Tor a Permit.o construct and/or instaii the work daSC7lJed. This appiCatlon Is r jade in cornpiiance with Sar, <br /> WELL n CLocatloCounty Development Tide,Chapter& 1116.3 and t.e Standards of San Joaquin County Public Health Services,Envirer rental Health Division. <br /> WELL n_� (,y I <br /> Cross StJoet���,p(}Sf Clty <br /> l� <br /> -- <br /> � <br /> ZPAhsosneess <br /> or s <br /> PROPERTY OwnAddress :p _ Pwoei# <br /> C�7 ContracteeCity <br /> AdcressX1- W <br /> 9?30 <br /> CIy!,e1e, �p <br /> Consultant 1 Sub Contractor r �L� �Fr - 112 <br /> ZCi'U s�'ll�t Ltb1'tIJ B� Gty v� <br /> Lica. Phcne# <br /> GIS Coorcinates:X Addres <br /> Y Township Range <br /> �ect�r <br /> WORK TO SE PERFORVED- <br /> `6k'flE'0!WELL!2CRjt1:3(CP-,GEOPROBE,HYDROPUNCH.H/,ND-AUGER.OTHER-) <br /> 0 SOIL BORING a Q DESTRUCTIO\(choose type below) <br /> v`LL# NnWt, Nltl� t •i. t7 <br /> 'Other. OVER•SCREPRESSURE GROUT <br /> COMM NTS: Grout Specifications: <br /> TYPE_ OF WELL INSTALLATION�TYP NSTRUCN SPECIFICATIONS <br /> XVONI ORING X--10LLCW STEM DIA_OF BOREHO' MULTIPLE CAS NC-17 Q YES t <br /> I7 EXTRACTION F,AIR HAAIMER'DRIV= �U <br /> N CASING THICKNESSg _ vr=lL USING DIA--__a_ <br /> TYPE OF CASING: a STEcL )Irvc <br /> 1?VAPOR Q MUD ROTARY DEPTH OF GROJT SEAL S <br /> 0 qts¢ TRc1.ilE Tl'DE 70 4F USED' D AUGERS Q N;tSE <br /> PARGE C:USH PONT C-POUT SEAL PU\1P'e:.: <br /> [I SOIL BORING Q.-iAND AUGcR GROJT SPECIFICATIONSn Yes�No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3t7') <br /> fi OTHER A=PRCX-BORING DE?TH � <br /> ---�. _0 30LTEC TRAFFIC BOX or 0 STO`J=PjPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED?N _(:f YES.lis:spe-iTcaticns here). <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 Or;' an s and Regul ions, and all applicable California State Laws. <br /> Signed x 11 ' <br /> Tine/Company <br /> Print Name ffC�,t;T <br /> Date_ 101 Z 3�O I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES : <br /> WORK PLAN DATED: LZ / <br /> Appilcation Accepted By Date Issued `l�3a�� Area <br /> Grout inspection By Date Final Inspe�lon By Date <br /> Destruction;nspecticn 3y Date <br /> COMMENTS ICONDMON3 <br /> ACCOUNTING ONLY: Al D# I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY O4TE PERMIT/SERVICE REQUEST# INVOICE <br /> b �� �a 27 9 <br /> o� spe <br /> C-57 WC -WATVFC !'.%i7 1 0++0,+ of An+t .:� a: ♦ �-- r <br />