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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health <br /> eal sDivision. <br /> WELL LocationE. Mrt INjt-. jiDew At-t� Cross Street AmozioO SI City SMC.KMII� Zip l o� Parcel# <br /> P.0•BoK 1110 Ci S'P�1•-Yay Zip�S2L 8.Phone# �ay- 1.�-°y <br /> PROPERTY Owner ?,ANL - Sty cyto A Address ty <br /> G�<11S9S251 Lic#i`3965 Phone#a�Z-3S� <br /> C-57 Contractor 1 'r SC•1t 12'NM�'fAlLtddress 35�1 SN,:a 15 PLAc,E ciryVAL(.C4 'Z p <br /> Consultant/Sub ContractorroNDb1L't11'RttFTfa.FINd-o4(e-5Address ityStnc.IcTDN Lic# Phone#234'0-Q8 <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 0 OVER-BORE <br /> SOIL BORING# S 0 PRESSURE GROUT <br /> U WELL# <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS O WELL CASING DIA: <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 MULTIPLE CASINGS?p YES XN <br /> NA <br /> U EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS t A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> U VAPOR 0 MUD ROTARY Dt PTH OF GROUT SEAL TREMIE TYPE TO BE USED:, U AUGERS U HOSE <br /> 0 AIR SPARGE PUSH POINT(aP GROUT SEAL PUMPED: p Yes '%No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT <br /> ECIBORFICANG D PTH �0C EMU BOLTED TRAFFIC BOX or U STOVEPIPE <br /> 0 OTHER: 0 OTHER . <br /> CONDUCTOR CASING PROPOSED? NO (if YES,list specifications here): <br /> 'COMMENTS:A IM4 c- r-I 13oSLl (35 301 lJSln•f,C�D,IR�Ci WSh Co-LEcy 2 S ILSA.A� 1L0 �h CA(0 BbgiNC • A'9VAou( <br /> I �lNe Ta -Jt✓rTH No SAHPLWI WbVI IU ;'VF tC ( 1 hl GULWIT CEM�iI/T <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 Ordi nces, Rules and Regulations, and all applicable California State Laws. <br /> n Titre/Company6uV SIoEgAcrS7 /�, � <br /> hD62 R'r't4 I+�NNOLcC1rE3 <br /> Signed)( � // <br /> Date 11/6�aZ <br /> Print Name MIc" '- DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued 1141!4-115 Z Area±5—A <br /> Sh <br /> Application Accepted By Date <br /> Grout Inspection By M--O� Date / B OZi Final Inspection By <br /> Destruction Inspection By Date <br /> COM- ENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 0 �`� - OS(v 187 l 11 l yovSR#Oa1401 <br /> C-57_ WC_WAIVER,_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 9/27/00 <br />