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WELL ORMIT APPLICATION FOIE SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 /> �Ef• W¢� i.�dStY A'� i_,.�/.�,, S��KTO.J Assessor's <br /> WELL Location Cross Street City ��F Zip 952r'S Paroel# 137-370-02 <br /> 10 S N. Et-Ce/wcb <br /> PROPERTY Owner SIiQPTCNJ R.C�,A Address %'r- SL,,vr Zoo —City-2 l ,4-mz zip95Zoz_ Phone#tom -7` 7 _n 1/ <br /> (7Mc.'D <br /> C-57 Contractor CASCI�CC �L. 1-15 Address 3832 0r e?- C,ki3 CityK_---5P. ZipRS7yZLic#j12S/bPhone#C9/1- 4IfC-)l6 <br /> 30117 y_jL§.-,F ", 17.^ f 0 <br /> Consultant/Sub Contractor SES Z'.Jrnc,wrro.ncAddress Su.- loo Cityl.�.nc. Lic#w�N'P- Phone#�9/G� <br /> GIS Coordinates:X ,Y ,Township I.J Range 6L Section I(� <br /> WORK TO BE PERFORMED: <br /> 0 NEW W ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# 0 OVER-BORE <br /> .It W ELL# CiPe—R- 0 PRESSURE GROUT <br /> 'Other: 7` Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y// <br /> 0 MONITORING RHOLLOW STEM DIA.OF BOREHOLE It" MULTIPLE CASINGS?0 YES &NO WELL CASING DIA: <br /> AEXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH- YO TYPE OF CASING: 0 STEEL RPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 21-Y/ TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes Po (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: x1",V- Ce. e-,T' <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30/ $BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A7 D (if 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 /> Signed 11�__ Title/Company QtiOTL� C7eai,oySi, Sem -LCL <br /> Print Name 1VipWAL-. `f, P&&ye-yL Date `fI/Vb3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued O/ 20 Area <br /> Grout Inspection By Date 17,''Final Inspection By Date <br /> Destruction Inspection By ✓ Date <br /> COMMENTS/CONDITIONS- <br /> R <br /> G ONLY: AID# <br /> FEE INFO AMOUNT REMITTED CHECK# RECD DATE PERMIT/SERVICE REQUEST# INVOICE <br /> $ q .�v S 32I^/, _'N3 SR# 3 fjq'3S ] 11 63 t{ <br /> ^-57_ WC=WAIVER_ C-57 Letter of Author6ati 0 <br /> o sign permit_Encroachment doc_ 9/27/00 <br />