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WELL PERMIT APPLICATION FUR <br />AL <br />Ercl'-!1-1--,, <br />SE <br />iTc: <br />TH <br />pvi ION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE§juN <br />M <br />1 VW IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 952C4VIR ONMENT HE <br /> <br />(209) 468-3449 PERMIT/RVI <br />ba — 5-14-._ 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 Jo,pin County Public Health Services, Environmental Health Division. <br />5°V. <br />Assessor's <br />WELL LOCatiOT1 rilie< 4/1- <br />- <br />1 <br />,- <br />1 <br />e <br />6 <br />ee. <br />e§ <br />F-g Lai1n44 <br />b <br />4 <br />ie <br />1 <br />- C <br />2F <br />ity <br />- <br />9 <br />Cit <br />Z <br />5r7/ <br />-4 <br />b‘4AcIt <br />ip41-7522)5 Parcel# <br />PROPERTY Owner214 4:t_ AddressD3R Zip Phone# 466 <br />C-57 Contractor 1.4626,44-69-2._ /2241 Addres . IteeS e-kCity P‘6 Zie-Nkice6)-29)PhoneiKijb /2n <br />Consultant / Sub Contractor Ace- - Alf Address 5r .7 L5Aa , a City gLic# PhorJfi i49/2 1 XtD <br />GIS Coordinates: X , Y ,Township Range Section <br />K <br />EW <br />TO BE PERFORMED: <br /> <br />WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />El SOIL BORING # <br />a OVER-BORE <br />El WELL # <br />ILI PRESSURE GROUT <br />Grout Specifications: <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />S2NITORING ).‘1LLOW STEM DIA. OF BOREHOLE /1.-3 / VoilMULTIPLE CASINGS?E NO WELL CASING DIA: o71/1c 11 <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 19- t) :TYPE OF CASING: EI STEEL ,I3.44C a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /414/-h TREMIE TYPE TO BE USED: IKJGERS El HOSE <br />a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: )3(Yes a No (NOSE: MAXIMUM FP5EE-FALL DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: k11N /L-- <br /> / Wier471-t-H-C-, --- <br />g OTHER: 0 OTHER APPROX. BORING DEPTH 'PS? ii * All.OLTED TRAFFIC BOX or a STOVE PIPE f‘ <br />CONDUCTOR CASING PROPOSED? AA ( if YES, list specifications here): <br />*COMMENTS: /17-1,075 i o ler ece 1(s- — irrt,ti ki c9LA.) .7-4,14 e_ in-00;-/' ,... <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 />I 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 />Title/Company <br />Signed x <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br /> <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: ;03.,. <br />WORK PLAN DATED: A5 :Ph i-Ca.../0 ,7r115 , .zipp <br />Application Accepted By AICA^-0-1--A <br />Date Issued epi/C PI <br />Grout Inspection By Date Final Inspection By :._ <br />Destruction Inspection By Date <br />.21/&/a7 • <br />Area <br />Dat <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />L.Col <br />C-57 WC -WAIVER <br />L4S-47 SR# 0°)A4'474 <br />C-57 Letter of Authorization to sign permit Encroachment doc 9/27/0C <br />AID# <br />AMOUNT REMITTED <br />P9°‘-'4:-) <br />FAC# <br />CHECK # REC'D BY DATE <br />\ <br />PERMIT! SERVICE REQUEST # INVOICE