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WELL ibRMIT APPLICATION FOF4 SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UHC IV <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 /> // !! /' wet ,, IICII U AI ,� 6, + ry l�nC prr� p <br /> Assessor's <br /> 1 <br /> WELL Location l0\O� 1.��2 WCber 2. Cross Street �� Co J Ci ZI Parcel# 137-370-02, <br /> PROPERTY Owner cL- Iv eSfotF 6,. Address .S �I�sra�o S'('. CItyZi&2Qo— e# <br /> � )'* 200 y <br /> c-s?commctorr ddress �SOQ.ae. clryAPa zpgY53 Lic#Phone#(9 33- AD <br /> Consultant/Sub Contractor SECO(L ,nlcf ra , Address 30171fjncre t2.1,, ettyYCo` c.w. LIc# Phone#Cglal61-0400 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ILNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# 0 OVER-BORE <br /> CC 0 yy(f,EL,4# 0 PRESSURE GROUT <br /> *Other- ..JcGI �I AVwr• Ytr�bpjr �- 'n1 k\� tc..tpp]hTGrout Specifications: <br /> COMMENTS: PC,<nt S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?BYES ONO W ELL CASING DIA:_ <br /> g EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS UR TYPE OF CASING: 0 STEEL O PVC B OTHER: <br /> 'VAPOR* 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes p1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING gHAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: R OTHER APPROX.BORING DEPTH S-IO 4et- 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> tt CONDUCTOR CASING PROPOSED? A)d (if YES,list specifications here): <br /> *COMMENTS: 1a0or �rO D�� ner ' a4 4-'I-OYle S. 602 ; r t Cor'I1faI pvr"del v.Pl <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 Ordin ces, Rules a�ndd Regulations,and all applicable California State Laws. <br /> Slpned x =7 �, Tlse/Company C in--� (�\a,- 1"s'I- /s l=Co dZ <br /> Print Name cG V r "A,-.,U Date 7 L 7/G f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: — <br /> Application Accepted By, e-`'l/ `-� Date Issued - �'""� a <br /> Grout Inspection ey Date Final Inspection By Date <br /> Desvuction Inspection ey z' Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# r:erw <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT/SERVICE REQUEST If INVOICE <br /> 2q01 I a q. CG' 6 , SR# 9 <br /> C-57_ W( -WAIVER_ C-57 Letter of Authof izati n# <br /> sign permit_Encroachment doc_ 9/27/0 <br />