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WELL PERMIT APPLICATION <br /> AUG. <br /> G2�TIGATIO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S CES IT !V <br /> ENVIRONMENTAL HEALTH DIVISION (PHS lIVENT <br /> 304 E. Weber,Third Floor, Stockton, CA., 9 >TISER4iICES <br /> A < <br /> (209) 468-3449 <br /> l3L>"PEFtIVIIT EXPIRES i YEAR FROM DATE ISSUED <br /> NON.�EFU�DA <br /> licakion is hereby made tv San Joaquin County for a pernit to construct and/or install the work described, This application is,mada in compliance with San <br /> pP Public Health 5arvi�es Environmental Health Division. <br /> i County Pub i h <br /> Joaquin County I7eveloprnenE Tltie,Chapter 9-1115.3 and the Standards of Sari Joaquin �' Assessor`s <br /> as <br /> r � ' S SkO WILL Location cross Street A�- City j,zp� e►� <br /> S�oc";' Zip�S.Zo 3 Phol16#� 4 to <br /> PROPERTY Owner LAP 10, Address 13Z CifY_ <br /> __.�f �1 i� J 7T7�7� �c,'7 LU Ri'Elone3. i <br /> G-57 Contractor <br /> Consuftan !Sub Contractor ��\ � a Jec�+.-a s Address S, City L�c1a�_ Lic# — Phone# 7-and S Z-7' Dm <br /> GIS Coordinates:X� Y Township Range Section <br /> 4 <br /> i <br /> WORK TO BE FERFORM<=D DESTRUCT �UR- <br /> pe boiow) <br /> JPNEW WELL I BORING(CPT,GEOPROBE,HYDRO PUNCH,HAND-AUGER,OTHER"} Il ORERE GROUT <br /> a WELL# i <br /> "Other. Grout Specifications:. <br /> GDMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE � CONSTRUCTION SPE=CIFICAT_16NS Y <br /> a MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?11 YES p NO WELL CASING DIA: <br /> o EXTRACTION p AIR HAMMERIDRIVEN CASINGTHICKNESS : TYPE OF CASING: U STEEL :A PVC. []QTHER: <br /> 11 VAPOR V MUD ROTARY DEPTH OF GROUT SEAL:. TREmiE TYPE TO BE USED:..0 AUGERS a HOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes EI No (NOTE: MAXIMUM FREE-FALL DEPTH IS�30') <br /> i <br /> SOIL BORING jI HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER; I]OTHER! APPROX.BORING DEPTH . 11 BOLTED TRAFFIC BOX or (I STOVE PIPE <br /> ` \ CONDUCTO;•:CASING PROPOSED? (IFYES,list specifications here)' <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKINGS HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> F <br /> I hereby certify that I have prepared this application.and that the work will be done in.accordance with San Joaquin <br /> County Ordina R d-Reagoons,and all applicable California State Lave s. <br /> r � r <br /> Slgned x TltleJCompan <br /> r <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> { SITE MAP IN UNIT Iii FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 5 _ <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By pate Final Inspection By Datz� <br /> Destruction Insgectian Sy Date <br /> COMMENTS 1 CONDITIONS: ls� r —F � 7� <br /> Zj <br /> ACCOUNTING ONLY: Ala# <br /> a l�iS-S - rte <br /> 3 <br /> PE CODES FEE INFO AMOUNT REMITTED CHE=CK# R 'D I3Y DATE PERmrr/SERVICE REQUEST# INVOICE <br /> ov o1 3®c) ?1211d V- -3 o: 1 <br /> C-57 WC -WAIVER-. — C-57 Letter of Author ctI i o sign permit__,_Encroachment doc 9/x7/00 <br /> i <br /> EO 30b6 �i00�� Hl�L SF17E89b60Z 99 : TBBz/8L1z0 <br />