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WELL PERMIT APPLICATION FC)KM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED plication is made in compliance with San <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of Q4 San Joaquin County Public Health Services, Environme Assess th Division. <br />yGD AST YSC�k��r- �` Zip ! '/ <br />WELL Location Cross Street ( City 533 Parcel# a [baa_ 3/U , <br />$141K{ City � Zip Phone# �%f <br />PROPERTY Owner e E C Address [- <br />// ;t )s- rf�r Sf Ci S1 C1k zip Lic# PPhone# .70- gyp -13115- <br />C-57 Contractor /1'leld �� Address 8 % ry cfr'��IOA <br />.i �/'y^1 & /off' 0�3 ipr��'Wlircity ic# Phone# �� " �'G S'�171 <br />Consultant /Sub Contractor Address <br />G , Y Township <br />Range Section <br />IS Coordinates: X <br />yy PERFORMED:DESTRUCTION (choose type below) <br />EW WE / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND AUGER, OTHER') 0 OVER -BORE, <br />0 SOIL BORING # PRESSURE GROUT <br />WELLIf2i 3 Grout Specifications: <br />'Other: <br />COMMENTS: <br />TYREOF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' <br />ONITORING HOLLOW STEM DIA. OF BOREHOLE MULTYFE CASINGS? 0 STEEL YES OIVCLLDIA: <br />O OTHER <br />XTRACTION AIR HAMMER/DRIVEN CASING THICKNESS OF CASING: USED: AUGERS OSE <br />D E O ' TREMIE TYPE TO BE US <br />0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: ff%es 0 N�� M 6�UoFRE -F O DEPTH I 0 <br />0 AIR SPARGE 0 PUSH POINT <br />o <br />p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 2 D BOLTED TRAFFIC BOX or STOVE PIPE <br />0 OTHER:_O OTHER— APPROX. BORING DEPTH 3 0 <br />CONDUCTOR CASING PROPOSED? A10 ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCCRROACRHMENT OU RED PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS INA +77 <br />hereby certify that I have prepared this application and that the work will be done in accordance with Swr0oaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />/^ <br />� <br />Title/Company ✓TIr�T tO�O�(s� <br />Signed x <br />Date <br />Print <br />DEPARTMENT USt UIVL.Y <br />(vt Ci V" -4-c- c_ j <br />SITE MAP IN UNIT IV FILE, ADDRESS: I <br />WORK PLAN DATED: <br />Date Issued S 2� G Area <br />Application Accepted By "— Date <br />r Date Z Final Inspection By <br />Grout Inspection By !! A� ti <br />Destruction Inspection By Date <br />COMMENTS /COND <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE bL PERMIT / SERRVIIC�REQUEST # <br />��iC�l ��(.��'r ►�'-t 15 � � � ,mac t� <br />C-57 W(_-WAIVER—C-57 Letter of Authorization to sign permit Encroachment doc <br />INVOICE <br />9/27/OC <br />