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• A* • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> (_x�,•y D ( gyp ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> �0` 304 E. Weber, Third Floor, Stockton, CA., 95202 VIRDI'c�C <br /> t C.� (209) 468-3449 V OFF <br /> cef <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 /> Assessor's <br /> WELL Location aGgOj s liac,4rtl'Wf- Cross StreetA,7rac 61 Cty Trace Zip 5376 Parcel# .zt1&-130-09 <br /> PROPERTY Ownerof T�Address 5210 Trac4 0Ivc 5-C ity T7aCTZip �5J 376 Phone# (LO Z31-yYZO <br /> C-57 Contractor �J iron(_°., Address ally AaavtS sive. City Lem,dro Zip yyS7JLiciF 7O5y17Phone#(5/0) 56b'-7(,76 <br /> Consultant/Sub Contractor Acton / l <br /> ,,�,,Il ickelso- Address b0H9R1MafkWCity HILiS Lic# 1755oYPhone# (S333y-7$52) <br /> GIS Coordinates:xixjLaom5 ,Y LONG: -/; ''/1;SYYSTownship 0e Range----( Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> - OEW WELL!BORING(CPT00 BOR NG#OR UGNCH,P7ND-AUGER, OTHER') 0 D OVER-BORE <br /> .kS <br /> WELL# I G# _ 0 PRESSURE GROU*Other.•OtheGrout Specifications. rte Ltt Ceme✓Yf <br /> COMMENTS: E,C. 00A<hinwPerinifin 5vec{ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ,7S MULTIPLE CASINGS?BYES ONO WELL CASING DIA:N A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS LVA TYPE OF CASING: D STEEL D PVC D OTHER: ADN'2 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL total de TREMIE TYPE TO BE USED: D AUGERS ,DOSE <br /> 0 AIR SPARGE -aPUSH POINT GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> j]iSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: maf (2,,neai <br /> 0 OTHER: tl OTHER APPROX.BORING DEPTH '50je('L 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_N0 (it 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 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 /> signedX 71Title/Company Prate tt�uinee�J'�Q tm M"cl<el ori <br /> Print Name .n Iiok�,iL krAyAmo A Date <br /> DEP�AjRT�M/ENT USE ONL <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ` W <br /> WORK PLAN DATED: <br /> Date Issuedg'O3 Area <br /> Application Accepted ByFinal Inspection By "^ Dale <br /> Grout Inspection By Dale <br /> Destruction Inspection By Date __--- <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# r=nrx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUES� INVOICE <br /> /,$L r 1 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_E7 a�03n�DU 927/00 <br />