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WELL IORMIT APPLICATION FOTO SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT 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 /> 0 W¢ r Assessor's <br /> WELL Lxatlon 7 <br /> Cross Street l-UA roi�Ciry C,,6 Ae hzZip Parcel# 127— 7 74-C3I <br /> PROPERTY Owner F'S� ( 'I ''Mj/ <br /> Address-Y.0 1�2"X 71 Q� CitYS4 CkkC1 ZIP� <br /> �Phone# 2aqH7J <br /> WGY2/2 <br /> C-57Contractor t AddressGpZAit 200 Cityyrl ',Zi 2YO Lic#ScLPhone#(92t)?/ <br /> Consultant/SubContractor C dress o17 Uqo R�pity `b <br /> Lic# Phone# <br /> GIS Coordinates:X ,Y ,Townshlp Range <br /> Section <br /> WORK TO BE PERFORMED, <br /> ®NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION(choose type below) <br /> t]SOIL BORING# OVER-BORE <br /> < 11 W ELL k (I PRESSURE GROUT <br /> *OMr. S_ �— rr\d 1� i ge.x 1 Grout Specifications: <br /> �i nt7 <br /> TYPE OF WELL INSTALLATION TYPE _CONSTRUCTION SPECIFICATIONS <br /> E MONITORING Q HOLLOW STEM DIA.OF BOREHOLE��MULTIPLE CASINGS?0 YES ONO W ELL CASING DIA:_ <br /> 11 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS A- TYPE OF CASING: H STEEL ()PVC []OTHER: <br /> ®VAPOR ()MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS [I HOSE <br /> 1]AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: l]Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 11 SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: ben'�tan <br /> a OTHER: n OTHER APPROX.BORING DEPTH r-10 -Feet- 1]BOLTED TRAFFIC BOX or []STOVEPIPE <br /> ��''�-,` CONDUCTOR CASING PROPOSED? �o (if YES,list specifications here): <br /> *COMMENTS: Ua rx r 3 i J2e-,r =-J� Cw.jva1 <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin ces, Rules arXi Regulations,and all applicable California State Laws. <br /> Signed �.--e�'t Tike/Company -I— la <br /> S <br /> Print Name R V f5 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By. v �L /0�. <br /> ate Issued Area <br /> Grout Inspectlon By Da Final Inspection By Date <br /> Det;M on Ina ction y Date <br /> COMMENTS/CONDITIONS- <br /> -------------------------------- <br /> ACCOUNTING ONLY: AID# <br /> Pnrx <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 9q � 0 C 6 Z 3() l #A72' <br /> SR# `t` 9 '� <br /> C-57 WC -WAIVER_ C-57 Letter of Autho zatio o sign permit_Encroachment riot_ 9/27/00 <br />