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WELL PERMIT APPLICATION AM 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 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> u1M5 W w r S{ocL Assessor' D Z <br /> WELL Location �`•fr cyac Cross Street L�AW1v. City � Zip�15 ZJZ Parcel# 1�1-26-b)-It- <br /> PROPERTY <br /> 'Zb' � <br /> PROPERTY Ownerpo,\kr. \4kAu4rr.Af ZNt- Address445 W Wc6er Aj. A(�l City,5 oQ{or Zip 5 2A"-Phone# <br /> C-57 Contractor !V ( r)AkK y4(, Address City Zip Lic# Phone# <br /> sulta /Sub $w1cZ1L <br /> on ractor Cho-yam'^6QR 41? Cbc'41" Addressc qO K0\1 CGAtir, 9"VV_City0m Lic# Phone#CIZ5 -Al.(.-Z40-7 <br /> GIS Coordinates:X L 41 , sb o ,Y 4-L o 1 51 ,Township 10 Range (o E Section i J <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION(choose type below) <br /> ,O SOIL BORING# 1 0 OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> *Other: Grout Specifications:'T(YA+Mtc gWa.:b IKcI U.ra.,, <br /> COMMENTS: IAIAIVa SQA. pw%� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION_SPECIFICATIONS <br /> 0 MONITORING ]!�HOLLOW STEM DIA.OF BOREHOLE L Ir MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC U OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z'5 TREMIE TYPE TO BE USED: 0 AUGERS .8 HOSE <br /> 0 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: 0 Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> $SOIL BORING U HAND AUGER GROUT SPECIFICATIONS: 00. ciz'., . e� <br /> 0 OTHER:_U OTHER APPROX.BORING DEPTH Z S' 0 BOLTED TRAFFIC BOX or 0 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 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 Regulations, and all applicable California <br /> j State Laws. /) <br /> Signed z &' rlk \0 D�M-Dy Title/Company `Ro1kb <br /> Print Name YAarlc W 1I), PMS Date -7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: p 700 <br /> Application Accepted By �'�' Date Issued _ 1 i �- Area <br /> i <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: RGR//U(a CgNh'CT f,� L6FY C N CLaN&r WI-[E( " AS46P- jN5lD& BD�E fOLF <br /> ACCOUNTING ONLY: AID# <br /> rnrn <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE tPERMITI SERVICE REQUEST# INVOICE <br /> � 75 � Y Z� �Z ]O 6+3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authoriiation.4o sio permit_Encroachment doc_ 9/ <br />