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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL. HEALTH IbIVISION (PHS-EHD) � <br /> 344 E. Weber, Third Floor, Stu�,Kton, CA., 95202 <br /> (209) 468-3449 H <br /> N N•RE= RIDABLE PERMIT Y TE ISSUI=D. P <br /> Application'Is hereby made to San Jcas}uin Couny for a permit to instruct and/or install tY�e work described. This applUtion Is r lade in compliance with Sar. <br /> .roaquin County❑eveioprnerit i Itl_,Chapter.G-1 116.3 and tY.e Standards of San J02cluln Counsy Pu�Ac HeaH1t SeMces.Envlros re Assessor's f 7ivisien. II <br /> Cross St;oet w City <br /> WELL Locatfon_ W• -- i� <br /> ACdress k�t City�_ZipZi Phone# <br /> PROPERTY Owner 1 <br /> Adcress 5 `GG CI�ySlt ZSR_ ul L;c��l�Rf�t1P^oneri ���! <br /> ` <br /> C,57 Contractor 1 <br /> �vt�_ � �'�� Citsr�u�L-� Phcne#�Z� <br /> Consultant l Sub Contmctor/�_ =� s <br /> Y Township L k Range �ettr <br /> GIS Coorcinates:X iM <br /> WORK TO BF PERFORVECI <br /> �[ FANCAUG.R,OTHER'.) 0 OESTRUCTIO\(coose type batbw) <br /> ME-vjWELL !ECRIIIS(CP GEOPROBE.HYDRCPUNCH. <br /> a CVER•BCRE <br /> 0 SOIL BORING# Q PRESSURE GROUT <br /> .ff�VELL#_ tAld�i{ <br /> Grou:Spidfcattons: I� <br /> 'Other <br /> COMIAENTS' I I� <br /> TYPE O>=WELLINSTALLA I NSTRU N SPECIFICATIONS ip—)t�� <br /> DIA.OF BOR=':TOLE �bA I MULTIPLE CAS.NG57 0 YES p NCr WELL C.�SING DIA:: <br /> �OWTORING -iOLLCW STEM 1 . <br /> AIR HAMMEFUDRIVEN CASING THICKNFS3 In L L) Tl�=OF CASING: a STEEL PvC (j O i li=rte: i- <br /> ll EYTRAC i1CN C - TREMIE TY-E TO BE USED- a AUGERS 0 H,)SE <br /> 11 VALOR �]SAL']ROTARY I?cPTI-i OF GRC'JT SEAL 3 �" <br /> 11 AIP,.SPARCE (1 MUD-JSPTA GROJT SF-.AL PUVPED: [L yes KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER Gr�O JT S?=CI 1^.ATION5: <br /> l]dTFER: _� ,THER�� A=PRCX.BON iNG 0FPTH Ctj �30LTED TRAFFIC BOX or [)STOVEPIPE <br /> CONDUCTOR CASING PROP i SED? Q6 ( f YES.lis:spe;if3cations here): <br /> *COMMENTS; I iM <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 /> 1 hereby certify at I e p ared this application-and that the work will be done in accordance with San Joag4utn <br /> County Ce cos uses d Regulations, a I applicable Ca�Ilfornia State Laws. Ii <br /> an S <br /> TitcfCcrrtp y I <br /> Signed <br /> � <br /> Print Name DEPARTMENT USE ONLY <br /> ;h <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Dasa Issued I� <br /> � 1p Asea <br /> Application Accepted By Date <br /> Grout Ertspectlon By <br /> pate Final Inspea'lon By <br /> Destruction;rrpecticn 2y �f8 <br /> i� <br /> COMMENTS f CONDMON& <br /> i� <br /> ACCOUNTING ONLY; AlD# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHF-CK tt REC'D$Y 007E PERME REQ <br /> IT I SERVICUEST# INVOICF. <br /> .i <br /> 9/27/OJ <br /> Fn roo bm .nt doc <br />