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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />. • Assessor's <br />WELL Location_ 1L y- r�(. /Imo/ un r --Cross Street. - w �Qqf I K� City ' Tcr4C -r,,j Zip ?.52,0-Y Parcel#13?/Z, <br />PROPERTY Owner��EntV S p 6 CitAddress Tphone#� <br />C-57 Contractor FuemoGC-oSui,w—,s,/ Address/DpnB90MIJg�f,5t4440 City0AKt0 Zip "6o7Lic#7i2c/3 Phone#�SIo 7--q4 <br />Consultant/ Sub Contractor C"AVADL F►eT.4 r6ul.. INL Address City!gkXTo#J Lic# Phone zb'L�23�-cSl�r <br />ulTi � <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />`KNEW WELL / BORINGPT EOPROB YDROPUNCH HAND -AUGER, OTHER`) S S1T6 S D DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />`Other: Grout Specifications: TPE -Z_a,--&AAt.JT-j •C y _13,-WTp,u1Tx, <br />COMMENTS: S GpT BotZuuG� -TbcA $pbAy / Got rlF <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES KNO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A.)/14 _ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -JD 5,494zACrc_ TREMIE TYPE TO BE USED: X S 0 HOSE <br />0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: VYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: AJ4-.4T* C-&rv%&AJ Z <br />OTHER: 4)T 0 OTHER APPROX. BORING DEPTH 154 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?.. O (if YES, list specifications here): <br />'COMMENTS:I47 `]'bvy�.)7 S C,PT SY�un1jSlluC,!S -J-D '�ISa'J � ' �Lt_6�T AA1A4-'r1PL& C•7R&LA"A .JA74At <br />n4r� � C TEFF rj C/�T �IT�S f}n� / 501L ,nP-JA96x cdP- / c-� � i NF CPT S/TE $ <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 Ordina ces, Rules and A,gulations, and all applicable California State Laws. <br />Signed x Title/Company ,) %�F� Gg;O -O6 ) <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: //� <br />Application Accepted By `�+ " <br />Grout Inspection By Date <br />Destruction Inspection B1161, Date <br />COMMENTS /CONDITIONS: ��� t�L� �;� �t / Ct ��z �6 <br />Date <br />Issued / 1/ruNlAIP1110 <br />Inspection 1=0 <br />ACCOUNTING ONLY: <br />AID# <br />![�`�'� <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D Y <br />DATE PERMIT # <br />INVOICE <br />IS30 <br />1 3,7. 00 <br />ss � <br />o <br />r -R7 \Ali'-\A/AT\IPD C-ii7 I attpr of Aitthnri7nti to einn nerrnit Fnrronchment doc 9/27/00 <br />