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209468343.3 FIFTH FLOOR <br /> PAGE 03 <br /> WELLPERIMIIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EID) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made fo San Joaquin County for a penult ro construct and/or install Ute wom described. This applicadon. s rnddo in,pempliance with San <br /> Joaquin Cauniy Owe o ggnt Tide,Chapter <br /> n¢�1115.3 and Uto Standards of San Joaquin County PubIIC Heallh Services,EncimnrnWal Health Division. <br /> WELL Location �N l'�{ S{_ t�tl t4l V� Cro53 Street AAAA Trel"t L city 6SW -% Arcelf s - <br /> PROPERTY Owner Atb��1- ..Ip 9rlt� pa�iy/ <br /> "�d1�°4` Address 1563`i &(-Ct,µ9..I C' ISS o <br /> C-s7 CCMraotor�oae,u,tpdd 'h' 11 zp4nL Phone#7A4 `•o3'D- }Lb9 <br /> �l Address� 60, 11.ti Cny�ah zP-*N `n uc#3&M Phonetl2 3 P/-t/3-, <br /> Consultant/Sub Contractor /L-T'C... AU--1C+OIat Address 01-i L-^P%lw FB CityM ucx Phone#�t Sa=r-Lttl <br /> GIB Coordinates:X Y Township Range Section <br /> WORK TO B£PERFORMED: <br /> 0 NEW WELL/BORING(CPT.GEOPROEE,HYDROPUNCH,NAND-AUGER,OTHER-) %r'JESTRUCTION(choose type below) <br /> Q SOIL BORING# 1v� <br /> Q W ELL# p OVER•SORE <br /> *Other' Grout SpeUflcadons: Q PRESSURE GROUT <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CON3TRUCTION BPECIFICATIONB <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE V.. MULTIPLE CASINGS?Q YES ONO WELL CASING CIA:_ <br /> 0 EXTRACTION Q AIR HAMMERtDRIVEN CASING THICKNESS TYPE OF CASING C STEEL Q PVC Q OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'tZ TREMIE TYPE TO BE USED! Q AUGERS Q HOSE <br /> 0 AIR SPARGE C PUSH POINT GROUT SEAL PUMPED! glees Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HMO AUGER GROUT SPECIFICATIONS: V-"►'11-l ly✓� <br /> WT ER; 't7- Q BOQ OTHER APPROX.BORING DEPTH L�EO TRAFFIC BOX or 0 STOVE PIPE <br /> Dc.,$}� CONDUCTOR CASING PROPOSED? (it YES,list specifications here): <br /> 'COMMENTS: J^1.C.� U A-#Ao .,.iw,,,y. S <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 Ordinances, ffules and Regulations, and all applicable California State Laws.n <br /> Signed L,J��sw �--�*-" — TtWcomoany_ ,111 rl'a3Z4 Ai'bj' / I} fIWfl&IG <br /> Print Name <br /> Gate 1 <br /> DEPARTIUIENT USE ONLY <br /> SITE MAP IN UNIT!V FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Dale Issued v ) GOri Area <br /> Grout Impection ByP V Date—Final Inspection By Date <br /> — <br /> Destruction Impaction ByA aw <br /> COMMENTS l CONDITIONS: )." tv <br /> ACCOUNTING ONLY: AIRF <br /> tfjEE INFO AMOUNT REMITTED CHECK a REC-0181 DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 0 ' lz �3Sam <br /> �r✓t b <br /> C-57_ WC_-WALVE; C-57 Letter of Authori eti o sign permit_Encroachment doc i 9/27/CC <br /> I' <br /> - ter:- -o—r+•isa+�e�.ae.,• <br />