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L. <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MITIGATION <br /> ! <br /> n?<�t, VIRONMENTAL HEALTH DIVISION (PH$-EHD) UNIT IV <br /> 1] 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)458.3448 <br /> NON-REFUNDABLE PERMIT LXPIREG 4 YEAR FROM DISE LUUED <br /> Appilcation is hereby made to San Josgain Cou*for a permit to construct andlor lnelall the work described- This appiicctlon Is made In aar>~plisnce with San <br /> Joaquin County Deevelaprharit'iltle.Chapter 9-1115.8 and the Standards of San Joaquin C*unty Public Health Srervlm%Environmental Health Division. <br /> WE LL f ocatlan_J, O Ktbe,�& - I�I}�gN Npp��cross street G city �Vaj T2+ zip Pa iif��s <br /> PROPERTY Owner PAW w�add?ess �•D� 2 PLII - --.City Tb W'Dd zip,9K.10 hone#� <br /> C-57 contrador l C'/� Wddress � :.4 A <br /> Consultant/Sub E",ontme or hl �-LL LACIM0 15'V &LA IWI-- tufty_ tL1W Uaa__--- Phonak, b Zsl- <br /> pt Coordinates:x Township Range sedlon� - <br /> RM <br /> EW WMLJ BORING CPT GEOPROW,HWROPUNCH,HAND;AUOER,OTHER*) 0 DESTRUCTION Goose type below) <br /> sail.BORING N 0 OVER-BORE <br /> la WELL 0 PRESSURE GROUT <br /> "dtlsar- Gmut specitlealkos:, <br /> COMMENTS: <br /> TYPE or W 4 L INSTAL AMON TYPE CONMtjGj10t4.SP1 CIFIC&U0N5 <br /> a MONITORING 11 HOLLOW STEM 'DIA.OF BOREHOLI, -- _MULTIPLZ CASINGS?fJ YES []NO WELL CA81NO D1A:__ <br /> p EXTRACTION II AIR HAMMER/DRWEN CASING THICKNSW_TYPE OF CASING: flSTEEL Ii PVC [i OTHER: <br /> II VAPOR lI MUD ROTARY. DEPTH OF GROUT SEAL TREMIE TYPE TO BE;USED: it AUGERS CHOSE <br /> II AIR SPARGE p PUSH POINT GROUT SEAL PUMPED;'d Vis Q No (NOTE;MAXIMUM FREE-FALL DEPTH IS 30') <br /> )t$Qa.60RING I3HANDAUGBR GROU7SPECIFICKnONS: <br /> THER; HER CP77 APPROX.BORING DEP fFi ��D � ^,Q not.'t'EiD YRAIFFiC BOX or Q STOVE PIPE <br /> I CONDUCTOR CMING PROPOSED? 1*(iFYErS,list spedficatIons harel: <br /> I� NOTE: OFFSITE SORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby rtity that I mve repared this application and that the work will be done in accordance With San Joaquin <br /> County O ccs,Rules nd R lations,and all applicable Callfamia State Laws. <br /> Signed YitlelCompany 4;f re 9`T � 5� J`z� <br /> P*d Na Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT ill FILE,ADDRESS:._ >) 1b.,.,. <br /> WORK PLAN DATED' () IS a jQ 0 <br /> IApplkakm Accepted By l O "'C-s "! f)aU9 Issued <br /> Grout Inspection Dale Rnal Inspection By Date <br /> 0eattuction fnspection By Date ,! <br /> COMMEFITS!CONDMONs: <br /> At:COUNTiNG ONtY: AfD9 <br /> f PF CORES FEE INFO AMOUNT REMrffED CHECK RECD NY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> DO I C <fi ! p 7 �lh L 0ij sag32 <br /> C-57 WC -WAIVED_ C-57 Letter of Authorization to sign permits Encroachment doc_ 9/27/00 <br />