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( ��• -" �•••,• +...� �c,�Yo�oY ou rir in rLuum h'Hbt U2 <br /> WELL PERMIT APPLICATION Fl eW SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> I. ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> U (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 andtor install the work described. This application is made in compliance with Szn <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location )7of W.Murr►, 1naC � Cross Street T - S city S�K�on rp�/y_Parcel#-q 16-190 'U7 <br /> PROPERTY Owner�SGO (CJ�1,OrQ��r� A7ddress 134d /S l)I?tl Clry ` 'Jq'I 72 Zp Sbd� Phone# 1pb •7/7'-1' c2910 <br /> C•57ContraclorCq$G9jG prdk'hQ Address363) ClMec C'."je- City-11"R4'o I.S/ Lic>: 7SUPhona# 1ld tv_3fj-JJG� <br /> L 1 n t /I117tc,/c��i.//Tip ���� �Ltt <br /> Consultant/Sub Contrraactto7r&Vd.,,MC,,61 ReSIIVI;u.Sgddress73Oy. ,l IJr,5ijX1City�L->LU (1)�Phone# 9)23Ra�Jos <br /> GIS Coordinates:X 3 / V �� ,Y Id I d I .Township a N Range 6 Section ` <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER-) V DESTRUCTION(choose type below) <br /> p-SOIL SORINS# p OVER-BORE <br /> WELL#__10 13 PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS: i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ul <br /> C MONITORING XHOLLOW STEM DIA OF BOREHOLE E 4 MULTIPLE CASINGS?C YES *0 WELL CASING DIA: 1 <br /> [)EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS� $( TYPE OF CASING: O STEEL PVC ❑OTHER. <br /> C VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL C- 30 -TREMIE TYPE TO BE USED UGERS CHOSE <br /> AIR SPARGE 13 PUSH POINT GROUT SEAL PUMPED: P�es R No (NOTE:r.MAXIMUM FREE- L DEPTH IS 30') ,i <br /> C SOIL BORING C HAND AUGER GROUT SPECIFICATION 1 dC�IN,nr� L LL <br /> C OTHER; OTHER APPROX.BORING DEPTH_ r M0.X BOLTED TRAFFIC BOX or p STOVE PIPE <br /> lCONDUCTOR CASING PROPOSED?VO (if YES,list specifications here): <br /> COMMENTS: itJ �� ;SO_Qrr�� w.4115 F4CI1 . w `I a ,"..1 Q Spuh,e, pa �s <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS � <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,State Laws, and Rules and Regulations of the San Joaquin County. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS/� <br /> Signed x t�IPMtldiU Tille/Company 5(` 54'K Gu"10gr �/f r1 c5.�I✓�;vh5, <br /> Print Name ncjtl SG U r _Date 1 111Q I &I - <br /> SITE MAP IN UNIT IV FILE ADDRESS NVORK PLAN DATED ?Ll '1Yla ul°t ��. S+zcKt ar. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 0 Area- <br /> -7 <br /> rea ,,1 <br /> Grout Inspection By Date 1 �—I »Fnal Inspection By Date <br /> Destruction Inspection By <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE RE4uE5T# INVOICE <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_____ 7/17/00 <br /> I <br />