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WELLSERMIT APPLICATION FOO 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 /> �=DW <br /> Assessor's <br /> A '- q ty �scK�vZip Parcel# 3 <br /> 7-370_VWELL LocationStreet L,"4°�� S�3 <br /> Pew OL`ltq Sol WeS.T W=lSa _Aw, <br /> PROPERTYOwner_fiAweismf PA.er. dll& Address S'T� 'Fwo-L_ ZipgS2-1 Phone4t (2o4)9yY-TZ 47> <br /> C-57Contractor6%SCN.aLT '�LL.Lu.uc. Address 3$3]- yM�� CI"{+-�Ciry c.:.+-eeNa ZipgS7Y Z{ic#�I'7510 Phone#(9R)ISSY- 116f <br /> Consultant/Sub ContractorStC"'��"''U"""�c-'^s-,gddress3ej��<h tires City J^ Lic# Phone#C9/2� gC/-oyo6 <br /> GIS Coordinates:X ,Y ,Township I Range 6 Section / <br /> WORK TO BE PERFORMED: <br /> f NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING It 0 OVER-BORE <br /> 'WELL <br /> # —c'sP6 $—rtweo�SH rJP�T-11 aPRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS // <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES A NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSCO-Y J TYPE OF CASING: 0 STEEL )aPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL2r—4/ TREMIE TYPE TO BE USED: ''AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: N cyi r C"c mom,•-f <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 3D/ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? .0 O (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 I/""y/ Titie/Companv` 'r"a-T C]QWoS•5i / S¢C a,2 �^'ro`^"O��wL <br /> Print Name '1i Ma `/_ P�4dc,nL Date `!I I g)03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ((l, <br /> Application Accepted By ' " Date Issued 5_1?�PL �J Z`5, ?OeArea <br /> Grout Inspection By ( Date Final Inspection By Date <br /> Destruction Inspection B Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> rer« <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY FDATE PERMIT/SERVICE INVOICE <br /> mol 9j . 06- 3 sR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Author ion o sigh permit_Encroachment doc_ 9/27/00 <br />