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1I.N0V. ?Q, 20001 $; 19„,�20946ERM Sr"'AMENIv FIFTH FLOORNC. P. L_ e2 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL 14EALTH DIVISION (PHS-EMD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468449 <br /> NQN.REFUNDAELE PERMIT EXPIRES 1 YEAP FROM DATE ISSUED <br /> Application is hereby made to Sari Jmquin County fnr a permltto construct and/or install the work described_ This application is made in mmpllwce with San <br /> Joaquin County DeveloprnertTitle.Chapter 9-1115.3 and the Standards cf San JoaCum county Public Hearth Services.Environmental Health Dlvision. <br /> WELL Lneatlon� j,�NQ�1 L't Crass Sveet I.IIWr�-r'�aC ' lissesso�s <br /> a_ { Lr Zip ParrAli� <br /> PROPERTYOwn er WILL111VII Address ,u$3.-6 "�4Z1-- Yea._ City S7ae�r/ Zp9SZ Z-phon ZO9 - Y�Z <br /> C•57Contractor 7- � efl� I3j1 Address 1f� Y1dNlt- PRaK rlG ,i t= ,A z _t ICWV <br /> Consulmnt/Sub Contactor Gam•! ­-----Address-j�iU�6�CU�A�• Clty.� l� Lich Phone 5///�93"7�' <br /> Gl$Coordinates:X -.Y Tcwnship R$nge Section <br /> WORK TO RE PERFORMED: <br /> p NEW WEL1-1 BORING(CPT.GEOPROBE.HYDP PUNCH,HAND•AUGER.OTHER') U DESTRUCTION(choose type be)ow) <br /> )(SOIL BORING Q OVERBORE <br /> U ELL# PRESSURE GP.OUT <br /> 'Other. Grouts fications: <br /> COMMENTS: <br /> TYPETYPE a�F WELL IN$TALLATION'IYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING Q HOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASINGS?U YES a NO WELL CASING OIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL p PVC [[OTHER. <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS U HOSE <br /> o AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS, <br /> p OTHER: 0 07HER APPROX.BORING DEPTH U BOLTED TRAI-FIC BOX or U STOVc PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> *COMMENTS- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4$WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I herebrtify that l have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ancas, R ies nd ulations,and all applicable California State Laws. <br /> Signed x p Title/Company Z NVII-ONr'I Z- .SGIC.71 7:5-r <br /> Print Name itV1 19 p Date 7 !?u <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT Iv FILE,ADDRESS: C2 C13 <br /> WORK PLAN DATED. t,JQ 3 7_ <br /> ApplicaC:tion Accepted Ry (i�r�! i�-P )i_. Dato issued_ %/ ' Z O �� Area G Z 3 1- <br /> Grout Inspection By Date Final Inspection By Data <br /> DestrucLon Inspection By Date 11L <br /> COMMENTS 1 CONI)MONS: �e <br /> ACCOUNTING ONLY; AID'. <br /> PE COdES FEE INFO AMOUNT REMF TED CHECK* RECD BY DATE PERMR'/SERVICE REQUEST 9- INVOICE <br /> ASU/ �� `l — l ffS 3 C,0 " ��GJ C�.2 6 o <br /> C-57 WC -WAIVER` C-57 Letter of Authorization to sign permit Fncroaehment dor,__ 9/27/00 <br />