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'FILE COPI <br /> w WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> .SAN,JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> - ` 'ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 DN' IAS <br /> 03 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR 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 16 compliance with San <br /> Joaquin County Develo me t T11'tle,Cha ter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ro2npz Bry , SP,Tc,_ J_-G Assessor's 7 <br /> WELL Location S�� ,ZAe3er V1 gyW Cross Street City.�/ - Zp`-�'ZDS)Parcel#,{�/5�y,r22 / <br /> PROPERTY Owner,4��>9 V-2'1�f L"..�-g Addressg.,&-/91�yy City + c ZipQYt/d PhoneA25)'"' <br /> ��^^ / fV,!i1 Address0??6' �J161VA-'l City_V _ ip9 �_ '-d�ia <br /> C-57 Contractor> 2 - �'> ) Zi 37�Lic# /�"-ZS°, I,, � <br /> Consultant!Sub Contractor /C�CC7/1J�LL � Address -S�J"Zy��� city -7Lic�# 'y``� Phoned/ 4`d" <br /> GIS Coordinates:X� �' J .Y 3}`96 ,Township Range T c- �section CD <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDRQPUNCH,HAND,,AUG CHER'),/ �r(^i��(/E� !I a OVER-BORE <br /> XS, OIL BORING# ,J/2 Sr` Yl�j- d- V Ips a PRESSURE GROUT <br /> DWELL# _ _ I; <br /> 'Other: — Grout Specifications: _ <br /> COMM TS: t <br /> .A <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING $HOLLOW STEM DIA.OF BOREHOLEMULTIPLE CASINGS?tl YES ONO .. ELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 5-/1 S"O TYPE OF CASING: O STEEL XPVC H OTHER: <br /> 9---/�-SY4-5 <br /> 'VAPOR Il MUD ROTARY DEPTH OF GROUT SEAL�T-� yc TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> $AIR SPARGE H PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE'FALL DEPTH IS 30') I <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:/2e4,;4 <br /> vt < )/ <br /> a OTHER: (]OTHER_ APPROX.BORING DEPTH/yO/ds, JEI VE BOLTED TRAFFIC BOX11 or Il STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: (/'D f /y- r' 141 'e <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 accordancewith San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Title/Company Sr S <br /> Signed x <br /> /LCx 5 Date O <br /> Print Name_ ' DEPARTMENT USE ONLY <br /> Y/ �// . <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �6>� III 1—� <br /> p <br /> WORK PLAN DATED: 0100 <br /> Date Issued ea 0 8 <br /> Application Accepted By \` 2.� <br /> Grout Inspection By <br /> Dale Final Inspection By ate /0 2 F <br /> Destruction Inspection By Date <br /> III <br /> COMMENTS I CONDITIONS: <br /> n 'li• <br /> ACCOUNTING ONLY: AID# ' <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350► I~ � ' /If 5 G> 00 - I? <br /> doc 9/27/OC <br /> C-57 WC= ✓WAIVER_ C-57 Letter of Authorization to sign permit Encroachment <br /> I <br /> , I� <br />