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WELLORMIT APPLICATION FOI* 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 /> SZS "JEST hv6- Z.t•�ce,�,.J SToc,KTo-J 95703 <br /> Assessor's <br /> WELL Location Cross Street Ciry Zip Parcel# <br /> 5-rnuc�v.� 20 A- 3oita.�-r_o�.-..wosr. Scor-r�-J sz 35-Ss!;]I <br /> PROPERTY Owner Address za:, City ZipTPhone#(Zo9) 4 <br /> s �R-�u,w R�.n o `7 S7YZ <br /> C-57Contracto?(A` ' S. Address3%32. oAez- C�fLu�r Ciry CZips ) Lic#" 1I"D Phone# (911.) (y'$- 1169 <br /> Consultant/Sub Contractor .SEt,.`�5-.�-rtT.�=na""LAddress3ol'� �ILSo•uTri/oJ City, cR�K�oJA Lic# Phone# �916� `.-&I-DYUo <br /> GIS Coordinates:X ,Y ,Township 1'V Range 6 e' Section 10 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> RWELL# MW-1F1 Mw-t-13 MW-zu pPRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> j,MONITORING 'HOLLOW STEM DIA.OF BOREHOLE err MULTIPLE CASINGS?0 YES ,'g NO WELL CASING DIA:Z y <br /> ]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING: 0 STEEL )rPVC BOTHER: <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5- TREMIE TYPE TO BE USED: )(f AUGERS 0 HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes V No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: A-ce-C CQ-1K u"�� <br /> ]OTHER: 0 OTHER APPROX.BORING DEPTH Zs r �"OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?AyZ� (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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ,ounty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> >igned x I _,-ze, Title/Company P4�-W_T <br /> 'dnt Name 71*25 wtS Y' Date 1�' S/7003 <br /> DEPARTMENT USE ONLY <br /> 3ITE MAP IN UNIT IV FILE, ADDRESS: <br /> NORK PLAN DATED: I <br /> kpplication Accepted By ` - Date Issued �f�G Area <br /> Trout Inspection By Date Final Inspection By / Date�zL2'3 <br /> )estruction Inspection By ate <br /> ;OMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cera <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 2 Sf . T�q li 0 SR# 3 Zqt-5- j <br /> -57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />