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WELL PERMIT APPLICATION FdkM SITE <br /> P��CEz4�E� MITIGATION <br /> 2Q0k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> R� ENVIRONMENTAL HEALTH DIVISION (PHS-5202 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FILE <br /> sN �cN pa�T���N� (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services�Environmental <br /> r nvironme Assessor's­2 <br /> �O<Z i. �4 ] ! City .7t�;; �cF, Zip %S701 Parcel# 05 —320-10 <br /> WELL Location V10 <<►t✓3ta' Cross Street&it <br /> Cit J, �1�Zip f Phone# ,'? <br /> PROPERTY Owner Cddtl2Cc�"t �> I AddrrCe-ss <br /> 9) CC1x �! (3 City a:+gtVc; Zip y ri�Lic#��i'>XPhone#�5 � 5 i <br /> C-57 Contractor Address <br /> Address , <br /> I24� City � c Phone#f< <br /> Consultant I Sub Contractor •7�-t= ^"� address_ <br /> Township �m Range Section Aq <br /> GIS Coordinates:X-----6 .Y <br /> WORK TO BE PERFORMED. , <br /> DESTRUCTION(choose type below) <br /> D04EW WELL/E30RING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') �OVER-BORE <br /> 0 SOIL BORING# Q PRESSURE GROUT <br /> ��7--1 � �� <br /> 'Other: 'WELL# Grout Specifications: <br /> COMMENTS: ie <br /> - t 4-nJ OS-10 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �f <br /> o MONITORING /. HOLLOW STEM DIA.OF BOREHOLE 'a" _MULTIrPE OF CASING �STEEL ,� <br /> PYES if NO W <br /> p CLLR CASING DIA: <br /> Q EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS SC 9TI�� TREMIE TYPE TO BE USED: �AUGERS ,'HOSE <br /> []VAPOR [j MUD ROTARY DEPTH OF GROOT SEAL <br /> AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: V Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: ' BOLTED TRAFFIC BOX or [ISTOVE PIPE <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH }� <br /> CONDUCTOR CASING PROPOSED? (if YES,fist specifications here): <br /> 'COMMENTS: <br /> NTE: OFF TE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> O <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 Ordinances, Rules and utations, and all applicable California State Laws. <br /> Title/Company ?Oro <br /> Signed x <br /> Print Name .�zc l- �� ` ""5 Date <br /> DEPARTMENT USE ONLY <br /> --3J-5 AL!f <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3202 Wes m r- <br /> WORK PLAN DATED: f Se m b S 2 O <br /> Application Accepted By V I e✓ Y d �- 1" �n�T Date Issued Kay—O Area S <br /> Grout Inspection By YiG <br /> .11?CLAr - _—Date 311/ 6;$1 Final inspection By e : r� Date a <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: _ 0 S_ <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# tREC'D DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350 1 or 89.bo ` 99, 0o 0 2 0 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 9/27/00 <br />