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WELL PERMIT APPLICATION FIM 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 1 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 91115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> `` Assessor's <br /> WELLLocation 557.4 WES; INLb�/ Cross Street I-,ntal.. City$�k� Zip 952az. Parcel# 131^31-00'3 <br /> PROPERTY Owner //�clLJ6ls YOA h16Address 141 City S} Zi S �— Phone# <br /> C-57 Contractor !V ,7� I riC ' Address City Zip Lic# Phone# <br /> Consultant/So (6120 I4o1�dti k- F kv.� CA <br /> Gentraetor C%., y��P <*g ' Address 54t Ll 1. City Lic# Phone#925- 446-2606 <br /> GIS Coordinates:X (,HQ f SU' ,Y `'l L Ol$l S ,Township I N Range L,E Section lb <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> $SOIL BORING# ()OVER-BORE <br /> 0 WELL# D PRESSURE GROUT <br /> *Other: Grout Specifications: -TrCMm,�-�f0A hQc6 Ctmw <br /> COMMENTS: laollo. sot, � + <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING $HOLLOW STEM DIA.OF BOREHOLE i MULTIPLE CASINGS?0 YES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z ✓r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> &SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS:vVe1b C1 Aaz Fir -- <br /> 0 OTHER: O OTHER APPROX.BORING DEPTH Z'f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State,tLaws. y <br /> Signed x iV �1+-Lt. Tifle/Companj"�e V r404 r' /GIaA��- <br /> PrintName Marl'. W , il;nM'S Date -7h310z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Y /-X� t ° ° Date Issued 1 u` i �D Area <br /> Grout Inspection By Date_ _. Final Inspection gy Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Q YIl W-1—APW-1-APJ zvc9r CA54 b0Y$ o . May ori <br /> ACCOUNTING ONLY: AID# cnrtt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA PERMIT/SERVICE(REQUEST# IN <br /> 20 ( gg.00U I S L$4 ✓ ✓ OZ SR# 30 �, <br /> C-57_ WC--WAIVER- C-57 Letter of Autho zati o 5(qn rmit_Encroachment doc_ <br /> 'L4 kov <br />