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v <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH [)IVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YFAR FROM DATE ISSUED <br /> Appliptlan is hereby made to San Joaquin County far a permit to mnstruor and/or Install md <br /> e work dasalb_ . This appricatlon Is r lade in compliance with Sar <br /> :oaGuin County Development Title,Chaphx S-11 15.3 and the Standards of San Joaquin County Public Hearth Services.Emriror venial sa 01-SDivision. <br /> WELLLocanon_/d2 S•Gur�SyL <br /> Cross SVoet _city ZP--Parcel# <br /> Al eg Address. � Phoned U $3ycl <br /> PROPERTI'Owner� A )3� City s-'Iz ZP <br /> Adcress4l 1st Si- cl zp.94,o1 Lc# $ZP" �/o)73Y-4575 <br /> C57 Con7aUcr•YCPr rCt/�n.] <br /> � <br /> n�.,�7i'_ Address i7iN 2WZ;q . ' Gb Uc# Phone# <br /> Consui�M/Sub ContraRor� <br /> GIS Coorcinates:X_.,.. <br /> Y ,Township Range SeaYr <br /> W T BE PERFORMED' _ DESTRUCTIO\(choose type below) <br /> IEJ!WELL!BORING(CP-,GEOPROBE,HYDRGPUNCH.HAND-.AUGER.OTHER') CVER•BCRE <br /> OIL BORING#&T) �a R/-05 U PRESSURE GROUT <br /> pWELL# / Qfvf <br /> 'Other. Grout Spedficatlons: �r�� <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0-IOLLCW STEM CIA CF BOREHOLE 7 Y/a"MULTIPLE CAS NGS7 0 YES ffNO WELL CASING DIA:_ <br /> 0 EXTRACTION Ii AIR HAMMESXRIYEN CASING THICKNESS TYPE OF CASING 0 STEEL II PVC 0 O T HER: <br /> 0 VA,-OR G MUD ROTARY DEPTH OF GRC'JT SEAL/y0 t bD TREMIE-Y°E TO BE USED: 0 AUGERS .t7.+.')Sc <br /> p AlSPARGE ,BUSH POINT GROUT SEALPUVPED:'Ves 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 36') <br /> OIL BORING 0HANG AUGER GROUT SPECIFICATIONS:AA/ I'OM•�aul fa <br /> 0 OTHER: 0 OTHER APPRCX.BORING DEPTHX ¢LO" 0 BOLTEC TRAFFIC BOX or 0 S T O'P_P!FE <br /> CONOUCTOR CASING PROPOSED7 l fYt'.S.lis:speelhaticns here). _ <br /> •CCMMENT'S: <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyOr es ules and Regulations, and all applicable California State Laws. , f <br /> Signed s <br /> TitelCampanyd 'erd <br /> Print Name 'S�n`^y C 'VKY Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: t IS6n 1,00 A ick{ten <br /> WORK PLAN DATED: - <br /> Application AcceptedBy �N' "`-y Da:e Issuedl5 Area <br /> Cro��t Inspection By <br /> pats Final Inspeotlon By Date i3 <br /> Destn.ctien!rsoecticn By Date <br /> COMMENTS/CONDITIONS: — "•i n-! C P V 5 1 <br /> ACCOUNTINGONLY: AID# i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'DBY DATE PERMn18FRVICE REOUESiS INYOICG _ <br /> u,i- _WATUlon r-57 I Ptter of Authorization 10 Sign pe-mit_Encrooch.'nent doc_ 9/27/00 <br />