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FELE copy <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 Q t n d <br /> (209) 468-3449 V <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application'*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 /> Assessor's <br /> WELLLocation 95 Vallo'co Roup Cross Street � OIACity ac zip 75 7l;Parcel# :Z3U-09 <br /> PROPERTY Owner CoNSoudetl;9 Cp,v T/11A1FA Address 7S ul._(/AL Pe 0 City T(�et(� Zip S 7 Phone# �209�-$3!-yY?b <br /> C-57 Contractor Wt^odward 17?illi^(Address a0, Bcx 53 City die ViNa zip lyti7 ic#7IV077Phone# C7o7) 374-Y30() <br /> Consultant/Sub Contractor Acton Ai LLoICnAddress '30'RVR RJ ff6rhC+JS 1^ City -' t' Lic# 7/550$ phone# <br /> ✓L (9/b�y39"71J� <br /> GIS Coordinates:X. LAT: :i771L)K7NS ,Y LON(.'-lal.Y158 Wl ' Township 02 cS Range 05 Section 33 <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> }JEW W ELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 OVER-BORE <br /> 0 SOIL BORING# n p PRESSURE GROUT <br /> -aa MW',23 <br /> Other. �'fNELL# P'1 vJ <br /> Grout Specifications:_ 5/ bLavoita ZY5 °� u"i ceme^t <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> '"ONITORING AJ4IOLLOW STEM DIA.OF BOREHOLE_ `a'' _MULTIPLE CASINGS? `YES 0 NO WELL CASING DIA: aee <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL WVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 61 b,nlani��9y Offl f or un'C <br /> 0 OTHER: tl OTHER APPROX.BORING DEPTH 15011 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N 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, Rules and Regulations,and all applicable California State Laws. <br /> fiSF Tdle/Company 0 c'ic ('/ '`L-'tc� /•'i c <e( on,Signed x <br /> Date 4-/- 7-7J0 3 <br /> PrintName Robert (_ IAA ^ ^j DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> 75 uj vo-� Pro -rae,) ��- <br /> WORK PLAN DATED: 2-03 <br /> Date Issued_ /.- -� Area <br /> Application Accepted By - Date <br /> Date-Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By DateY.-- <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# Force <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorisation to sign permit_Encroachment clot_ 9/27/00 <br />