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WELL-PERMIT APPLICATION FMM 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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 'dl L/7 <br /> Assessor's <br /> WELL Location .Sl.SD /d'i-*-�} /l++/ ' Cross Street City �J/DGrG/D�S! Zip Parcel# 697-OYG^Q� <br /> PROPERTY Owner / *71) /fnVY Address SSSa 7/ CityJ�I�l�Tn/f Zip/�.SZo/ Phone# <br /> .n�ub <br /> G57 Contractor �� / /LNu� Address 3632 OMGG C�r%1_ City/ZGo..Ari�1- Zipf57YZ Lic#Z%n/0 Phone# <br /> Consultant/Sub Contractor S&Lo.G 7ew /L%L!//2� /40 IN/!�-v7u s�'Lic# Phone# <br /> -wrao <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> `,WELL# oewe_ WfvGL 0PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ^d�M ' �r 0-'MONITORING )(HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YES NNO WELL CASING DIA: ri <br /> DEXTRACTION 0\AIR HAMMER/DRIVEN CASING THICKNESS 5-- YO TYPE OF CASING: y�� <br /> 0 STEEL ,[JY"VC 0 OTHER: <br /> 0 VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL 'SSS% TREMIE TYPE TO BE USED: XAUGERS []HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ,[Wes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER,.-----__n OTHER APPROX.BORING DEPTH70 ''// DCBOLTED TRAFFIC BOX or 0 STOVE P <br /> CONDUCTOR CASING PROPOSED? 4 0 (if YES,list specifications here): <br /> 'COMMENTS: "G/A4 l L O r ]O ciC <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. I 'n <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqul <br /> -ounty Ordinances ules nd Regulations, and all applicable California Stattee/Laws. <br /> Signed x tl/ <br /> Title/Company ,/`/Gf IZ �T/�/����fQ/(�/f� <br /> 'rint Name L%l1lT- Date <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: 1 OC7 1V . 1 r Cr/ <br /> YORK PLAN DATED: z [ S c'Z <br /> .pplication Accepted By ( DIY N 0. Date Issued 6�1 2—O O Are <br /> ;rout Inspection By Q: t;a .�� Date zb O Z Final Inspection By. �AC4 Date <br /> restruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> Cehu <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> iso( ��-oma Sz6ze� 6t(J 45 z'DSR# 30d <br /> '-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />