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• FILE COPY <br /> WELL PERMIT APPLICATION FORM 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 /> C,,// rr fio6,nhcod Assessor' <br /> WELL Location _5qt.}�,, G T_tc ,A17-t' Cross Street �r f /, city St 0-' to A Zip C' 52 i Parcel# �Z.'Arg Zo <br /> PROPERTYOwner .1LJY1•? ribs. Address h�tJ a> PG3c.��.c 41,, CityJ�ocl:to vt Zip r' _-i' hone# D` 9a2-6'Z7-7 <br /> C-57 Contractor;'Jf'SZ'He'_yKyt Address 31331�tZQCx'3j ka� City�li-�-c1'1J�'f Z1 �T`�zlic#,7.$`/'7 hone#`�'%L-l�3cLJ'7-Z7L• <br /> Consultant/Sub Contractor �it✓rtvHtirfe•tti 14,j�. ddress two-4o' EUa ++Qity <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# MW' .I aPRESSURE GROUT <br /> 'Other: -r44ZU /Q c 14git:1I) Grout SpecificationsF.Q�! n i/ .� <br /> COMMENTS: "'� �`��— � LV <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?0 YES NO WELLCASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Qh,, TYPE OF CASING: [) EEL PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALQ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: ;KY ON (MyO-TE_MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: u fd Kt L <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH /OS POLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 8f0 (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County/Ordinances, Rules d Regulations, <br /> and all applicable California State Laws. ] 7 <br /> Signed x�J +-1 /f (tel:�(a.' t S L Title/Company�M/r+l n-)-��+^�� .i7 C / <br /> Print Name qty^P`nM IIQ rl n WI Date 16- 7o -6 1 <br /> /DEPARTMENT USE ONLY <br /> 56 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0"700 4) ?i — (a," -<Op8„ <br /> WORK PLAN DATED: /O D/ /1LtJQ a6 9 QQ to O <br /> Application Accepted By Date Issued �Q -Q/ Area 469 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 50 Xw) /3 4704731-3 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />