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WELIRPERMIT APPLICATION FAM <br /> [RECE V GD SITE <br /> W SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 14AR 1 S 7n05 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES <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 /> WELL Location-C" W- tdC-331=-� A-�1r . Lw<.:;,-.moi Assessor's <br /> Cross Street City 5 -E-`N-� Zip '1520j Parcel <br /> # <br /> PROPERTY Owner STor-K-ru-u 40A 2L 1� <br /> Address �+�-xr-y R- '- City �rcru.✓ ZIP'7SZaiPhone# (1&4) 93 <br /> C-57 Contractor.CA-S""N aX.c r-iv.u-j Address 31? ze_ Cv.C- Cily � v.� ZIP-2—S')VZWC#�1)S70Phone# 638_- <br /> Consultant/ <br /> 1(f-Consultant/Sub Contractor St<o` Address301' IGI �/.� Olty q Lic# Phone#C916 kb)-Oyev <br /> GIS Coordinates:X <br /> Y <br /> —,Township l'J Range 6 CS Section (V <br /> RK70 BE PERFORMED- <br /> KN <br /> ERFORMED: <br /> NEW W ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> (1 SOIL BORING#M_ w=S,L#/A t h <br /> HELL# _ 0 OVER-BORE <br /> *Other: Grout Specifica of n( s: ' U PRESSURE GROUT <br /> COMMENTS:/tty-}? 4 41 % -SS tc S�' •SSS. W-SY 9 <br /> c/ 655 w—SS N So' S5 <br /> TYPE OF WELL INSTALLATION TYPE C NS AUCTIO SPECIFICATIO <br /> -MONITORING H HOLLOW STEM DIA.OF BOREHOLE 'L MULTIPLE CASINGS?o YES ,®NO WELL CASING DIA:_ <br /> Q EXTRACTION :AIR HAMMER/DRIVEN CASING THICKNESS Z " TYPE OF CASING: H STEEL -g PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL4'V $b' /2u r THEME TYPE TO BE USED: AUGERS �FHOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ' as p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> B SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: .A.L4-Ct". e_. <br /> a OTHER: n OTHER APPROX.BORING DEPTHS� l>o/ BOLTED TRAFFIC BOX or ,STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 4J0(if YES,list specifications here): <br /> 'COMMENTS: W L2-S M w-SZ Il M1a-SS S�.ee.,.Q r=+y 4Sr-ro Sn1. LWeLL M.-S'f <br /> VW-1j 41L,1-515I <br /> r F•a�»� ff'S to To- <br /> 5Gf`T�L✓�-� �-xu.n I2S Tar O _ <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 /> 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 x Title/Com an Pti�C <br /> P Y h�sT J SL'� <br /> Pdnt Name _F Y04'� y- Q�4xC.x <br /> Date 31( '1/0!�_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted <br /> BDate Issued <br /> rGrout n BDate Final Inspection ByDestructiion Inspection 1 7,grc T <br /> By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cerw <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC•D Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> sol 21 . ate L I L III 3 q1 <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth9f izati o sign permit_Encroachment doc_ 9/27/00 <br />