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WELL-PERMIT APPLICATION r_�ZM SITE <br /> R[ECFU_�Z&QUINMITIGATION COUNTY PUBLIC HEALTH SERVICES UNIT Ili' <br /> JAN 3 p 2 VIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 4 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> ENV1, N:M )err�� ,�LTN �2U9) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� COP <br /> Application is hereby made to San Joaquin County for a permit to construct andfor instal the work described. This application is i mp th n <br /> Joaquin County Development Title.Chapter.9-1115.3 and the Standards of San Joaquir County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location 916 � i A.,_L �r�i�� -Cross Street S.�y Ciiy � rY�� Zip Parcel# 1 <br /> PROPERTYown.AV LOA Address &)-e <br /> City CCrlC�a�<��Zfpgszj3 Phonr#/ <br /> C-57 Contractor t' lC Address 534,40 s' Y�A.(� �.� • lty_$ 4 ,_--Zip Y XUc#�9'/7 PhaneJk/±Fj?65 r 3 <br /> consultant!sols Contrad.,Aoli: Lr1rz�aidrPe�lri stz l+address 3 ,�Dit• CLic#ftl GZ 7 Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> - <br /> 0 BE P FBRIYfED= . <br /> EV1!WEL BORI (CPT,GEOPROSE,HYDRO UNCH,HAND-AUGER.OTHE ) 11 DESTRUCTION(choose type below) <br /> SOIL BORING# <br /> OVER-BORE <br /> WELL# W_ -P-14a PRESSURE GROUT <br /> •Other. ^ MaN,7af, Ia L v Grout 31mcifications <br /> COMMENTS: <br /> TYPE OF WEL INSTALLATION TYPE CDNSTRtICTnON SPECIFICATIONS ii <br /> '`MONITORING X-HOLLOW STEM DIA.OF BOREHOLE { MULTiPLE CASINGS?]]YES J(NO WELL CASING DIA:_Z�T <br /> U E TRACTION 1]AIR HAMMER/DRIVEN CASING THICKNES TYPE OF CASING:-11 STEEL KPVC Il OTHER: <br /> ]]VAPOR ]]MUD ROTARY DEPTH OF GROUT SEAL TREiVIIE TYPE TO BE USED: AUGERS Il HOSE <br /> (]AIR SPARGE (]PUSH POINT GROUT SEAL PUMPED: �Y []No (NOTE: MAXIMUM FREE- ALL DEPTH IS 30')' <br /> SOIL BORING ]]HAND AUGER GROUT SPECIFICA-TIONS: X <br /> r <br /> OTHER []OTHER APQROX BORING DEPTH ' C OOLTED TRAFr1C BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROP SED?�_(if YES,list specifications hen:): <br /> *COMMENTS:&L LiJ L ' 0AI f l L 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE S OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN JOVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the ark will be done in accordance with San Joaquin <br /> County inanc R es a d Regulations, and all applicable C lifomia State Laws. <br /> Signedx TittetCo parry CJG� FL�LD lS7 �✓,9 <br /> `� Date at 24 OZ <br /> Print Name <br /> DEPARTMENT U E ONLY <br /> SITE MAF' IN UNrr IV FILE, ADDRESS; 7 <br /> WORK PLAN DATED: o <br /> Application Accepted ByDate Issued �� -------- <br /> Grout inspection 13y Date Final Inspection By Date------------- <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# ' <br /> PE CODES FEE INFO AMOUNT RENIIII ED CHECK PERMIT f SERVICE REQUEST# INVOICE <br /> i <br /> I271a0 <br /> C-57 WC -WAIVER C-57,1.etter of Authorization o Sign permit - Encroachment doc ; .�.�„ -;9. <br />