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WELOERMIT APPLICATION IORM SITE <br /> ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTj1'S8RV'IC MITIGATION <br /> 12 2Uu1 ENVIRONMENTAL HEALTH DIVISION I� C�kID w ,PNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 488-3449 <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 /> I i Assessor's <br /> WELL Location GO(J( j1LM,. _y i'LT LAAiL,-cross Street City-�7&il Lp(}�)/yParcel# /1/7 - 6fe-U/l <br /> PROPERTYCwneti, -a7V-ICI- UIlf �S Address SAO«c A'S �.F,yllr CIry Z1p Phone#%TG�-_�Zb <br /> ' I �� ?Anl(1�o <br /> C-67 Contractor W i _I i Addres_.-Yy9 rITV&12=� 2pt8 city�lKM✓4 zp95�7Z Lc# Phone#(916)fo -7276 <br /> Consultant]Sub Cont2ctorADVArVLtI (iGn�Alladdress 837 dAcJ 12-LV+o ClryS7ylC.7owl Lic#wZZ7 Phone# 1167-Ip�(; <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> ORK TO BE P RFO <br /> NEW WEL !BORING FIT,,/GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> L SOIL BORING# (Z 0 OVER-SORE <br /> O WELL# 0 PRESSURE GROUT <br /> *Other. (30 <br /> Specifications: <br /> COMMENTS (31 TU I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING HOLLOW STEM DIA.OF BOREHOLE_S_rMULTIPLE CASINGS?B YES O(NO WELL CASING DIA: <br /> 0 EXTRACTIONAIR HAMMER/DRIVEN CASING THICKNESS >`(A TYPP-��EOF CASING: []STEEL Q PVC BOTHER: <br /> H VAPOR B MUD ROTARY DEPTH OF GROUT SEAL T r&. cf7L TREMIE TYPE TO BE USED: AUGERS 1]HOSE <br /> B AIR SPARGE I]PUSH POINT GROUT SEAL PUMPED: KYes a No (NOTE: MAYJIV FREE- ALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: pba I E <br /> OTHER: fl OTHER APPROX.BORING DEPTH ! S-r Q OLTED RAFFIC BOX or 6 STOVE PIPE <br /> ' CONDUCTOR CASING PROPOSED?j.ID (if YES,list specifications here): <br /> -COMMENTS: I L F)06141410F)0614141 /rTG �J F� G/A13 LAW &Y.W4!i n <br /> — <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 prepar d this application and that the work will be done in accordance with San Joaquin <br /> County an a ules i ations, and all applicable California State Laws. / <br /> Signed x TillelCompany S%A'Fr Aai, 1'0- kDwAkN �rG,�UI,Cdt!/ ✓lei <br /> Print Name �L1,L a'- `I - Date /m - <br /> 7SDEPARTMENT USE ONLY <br /> G <br /> DD <br /> SITE MAP IN UNIT IV FILE, AESS: �/ Z*-aL Za- — <br /> WORK PLAN DATED: ����/ <br /> Date Issued <br /> Area <br /> Application Accepted By <br /> Grout Inspection By Date 'L / Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PECODES FEE INFO AMOUNTREMITTED CHECK# REVID BY DATE PERMIT/SERVICEREQUEST# INVOICE <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />