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i <br /> i <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SIE MITIGATION <br /> 61-'�, €r�� UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA,,95202 <br /> 209 <br /> i ( ).468 3449 <br /> tION-REFUNDABLE PERMIT EXR 11 EFROM TE= <br /> Application is hereby mads 10 San,Iaaq*County far a permit lo construct andlor install the work described. This avocation Is made In oempllanoe with San <br /> Joaquin County Developtho t 1'itte.Chapter II-1115,3 and the Standards of San Joaquin County Public Multh Services,Environmantsl Health Division. <br /> WELL Loealioe�,,,�� � J Cross Street G6�r`-'� O5y G Zlls <br /> Assessor's <br /> I#ors <br /> PRopunyownerr' A 'fP.Asti14 �tC W aIss T•D- 2 Ci 7Dd Asa <br /> I 1Y 2jP 6LPhone# <br /> Cb7GantraoWr C'` �, ddress� IL4 t&I one#,__ <br /> Consutlant/Sub Contractor _z Wt.(_ Address ]�,Il . �tyLldl Phone# SID ZS7'-2Bg$ g Z10 <br /> Oft oxxxtinates: .Y Township, Range SWIon— <br /> %7NEW WALL!BORING CPT ,HYDROPUNCH,HAND,AUGER,OTmER-) 1]DESTRUCTION(ohoose type be <br /> 0 SOIL BORING# Q OYER-SORE <br /> B WELL,0- <br /> D F'RBSS1JtZE GROUT <br /> Grout Specifications <br /> COMMENTS; °. <br /> INSTALLATION TYPE CQNS71 11=0H SPECIFICAI10N5 <br /> 11 MONtTORtNG 1]HO"W STEM 'DIA.OF BOREHOLE-. -- -_MULTIPLE CASINGS?[)YES d NO WELL CASINO;Dta <br /> 11 EXTRACTION p AIR HAMMERlDRIVSN CASING THRCKNESSy, TYPE OF C MING; O STr"EL It PVC Q OTHERL <br /> . Q VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAT�REMIE TYPE TO BE USED: 1]AUGERS d HOSt; <br /> (I AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:) Yes 13 No (NOTE; MAXIMUM FREE-FALL DEPTH IS 301) <br /> *ASOR.WRING 11 HAND AUGER GROUT SPECIFICAMONs: <br /> 'HER;__ - , „�, rHER�� APPROX.13ORING OEMI�f� 1�t3OLYEG 7FiAFFiC BOX ar 1]STOVEPIPE <br /> 1 CONDI)CTOR CASING PROPOSED? NO (if YES.5st spedfications hare): <br /> *COMMENTS: <br /> f NOTE: OPPSITI. BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNrr IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> i <br /> hereby Itify that 1 hRR1Ve Prepared this application and that the work will be done in accordance with San Joaquin <br /> County Q ces,RulesAnd R lations,and all applicable California State Laws. <br /> UC <br /> monad TIt1erCompany 67 r-e 9 y' 61- 5, 7`z`. _..._ <br /> _},Ir`tNan e /YI Lt c. GL)c ra/f=j-� Da '711910,1 <br /> - 2EPOTM,ENT USE ONLY <br /> SITE MAR 1N UNIT IV FILE,ADDRESS: R PiL -- <br /> WORK PLAN DATED: &J2 L) f S - C�j LQ 0 <br /> } +pplltation Aacep4ecl Byl-_ p „Date Issued , b Axaa <br /> Grout Inspection By —-- _____Date Final Inspection By Date <br /> ll! I C�iprt Inspection Bir Date <br /> .OMMENTS I C.0140 nONS: <br /> ACCOUNTING ONLY. AID# <br /> :�E <br /> M 114FO AMOUNT REMIT= CHECK# RECD BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> C . get — Q0201 Dm L ]IN11ol 3� <br /> --57 W--WAIVER— C-57 Letter of Authorization to sign permit_Ehcroachment doh 9/x7/04 <br /> Cf I--((? 0-F -1- <br />