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- <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> -% ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 Q <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��TGo 7— <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development Titley Cha ter r9-115?and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> {{�� � ��¢ }o�jL43 rs')o tl.ov ISX wL Assessor's <br /> WELL Location�Krl q 10' Ia3+uxsk Cross Street r� L��x Clty Lra Zip 5330 Parcel# <br /> ti 4„ IM raw I4„+� A ' <br /> PROPERTYOwneGr�f Stens �""� Addr :2 lt� City 13os ZipC)7-1%0 Phone# <br /> ` 0 14S?I -fycc- <br /> C-57 Contractor \M0&1UjQj. v.11t Address 5,4E 0 R%k j&x Rel city V Zip Llc# Phone#1a1-Y f Y--'Y GC <br /> Consultant/Sub Contractor s <br /> Addres , <br /> (4-7S+ City. +l�'n Llc# Phone# - I f <br /> GiS Coordinates:X ,Y ,Township Range Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> 1NELL#.„ jAw-13j &kw-iii . mw-(5' µw-ICl /� / []P SSUFIEGROUT <br /> *Other: Grol5t Specifications_ 4T Lrc�+rrrt ��- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ll <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE r MULTIPLE CASINGS?p YES NO WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS �C TYPE OF CASING: []STEEL *VC []OTHER: <br /> [1.1IAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL r TREMIE TYPE TO BE USED: []AUGERS OSE <br /> SPARGE []PUSH POINT GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE FALL DEPTH 1. 30') <br /> []SOIL BORING []HAND ANGER GROUT SPECIFICATION <br /> [}OTHER: _f]OTHER APPROX.BORING DEPTH. O XBOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordan a with San Joaquin <br /> County Ordinan , es an do ,and all applicable California State Laws. <br /> Signed Title/Company �n+�lttr <br /> Print Name h w Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADL KESS: JrO� s- r GoP <br /> WORK PLAN DATED: T!l —OZ <br /> Application Accepted By eee bate issued Z Area <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ,COUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3�o Sql S� R# DZ � <br /> C-57 ✓ WC -WAIVE=R C-57 Letter of Authorization to sign permit E c �� /9!27/00 <br />