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i <br /> Y <br /> iWELL PERMIT APPLICATION FORM SITE; , <br /> MITIGATION <br /> SEP 2 6 Z009AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> EI:VIROP _i'aENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> PE iv1iT�IIc,/SERr <br /> `' 'CES 304 E. Weber, Th(09) 468-13449 Stockton, CA., 95202 <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&1115.3 andtheStandards of San Joaquin County Public Health Services,Environmental <br /> Health <br /> ell Assessor's <br /> WELL Location le�lo6 S. % y SL-VD.- Cross Street ��l W City ,570.AGT0:�/ Zip Parcel# $9- 17-0-7 <br /> PROPERTYOwner VILA-b _Address (ST�< ) City.��� ^( ZipPhone# „// ""/�C-57 ConVactor{•Ilfi On AOC Address331Sf Au44 /M Zip 06 Lic# d Z7Phon 0 YZa y�33 <br /> Consultant/Sub Contractor '/ IrjD ash,{+,Ii1O �Ipf, Address � Sµ{hnJ OGD City ST,V4T� lLic# g2_ Phonew�ZZ-I�Y6T�L�� <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: - DESTRUCTION(choose type below) <br /> NEW WELL I BORING(CPVWELL#�—� <br /> EOPROSE,HY ROP NCH,HAND-AUGER,OTHER') - D OVER-BORE <br /> DPRESSURE GROUT <br /> 'Other: Grout Specifications: - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE'/n MULTIPLE CASINGS?DYES �NO WELL CASING DIA: /�A <br /> a EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS 1 TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY. DEPTH OF GROUT SEACro AL C Era TREMIE TYPE TO BE USED: D AUGERS HOSE <br /> - aAIR SPARGE dPUSH POINT GROUT SEAL PUMPED:. tYes p No (NOTE: MAXIMUM FREE-FALL DEPTH 1s 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: D I <br /> % <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH 'I S r- D BOL ED TRAFFIC BOX or D STOVE PIPE <br /> ,�1 CONDUCTOR CASING PROPOSED? f,10 (if YES,list specifications here): i� <br /> 'C�MMENTS:�� 5bll. gOH� 70 AM?A1�” A ACU/ f (5>aP /Ll�� TO. <u 2f'b�C.e <br /> IxeA11tz V�. rrO rsQGv) - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. tl <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. 1 <br /> I hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin, <br /> Countypr 7c s, R les and Regulations, and all applicable California State Laws. <br /> Tide/Company�� 'F Vf e&yl I s7�RDV <br /> Signed x '�j \.,�-�� � � <br /> Print Name 1AUL- v VI�� — Date C?/Z �O/ i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> t <br /> WORK PLAN DATED: �^ <br /> lfi Date Issued Y P`� Area �t <br /> Application Accepted By _ 0 F <br /> Date Final Inspection By te. <br /> Grout Inspection By / <br /> Destruction Inspection Date - <br /> COMMENTS/CONDITIONS: <br /> _ 1 <br /> ACCOUNTING ONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT/SERVICE REQUEST INVOICE - <br /> 9/27/00 <br /> C-57_ WC_WAIVER_ C-57 Letter of Autho z io to 19n rmit_Encroachment doc_. <br />'I I <br /> - r <br />