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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />!, ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />0� Y' ' 304 E Weber Th' d FI St L16 CA <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />Ir Ljt,r, oc on, ., 95202 <br />PE CODES <br />(209) 468-3449 <br />�. V <br />AMOUNT REMITTED <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />REC'D BY <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 />35o <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location ll>,o�S. EI T)C( 0�l Cross Street 2 �1 , Ci C Assessor's d/ <br />ty Zlp 9SZ�D Parcel# <br />PROPERTY OWner6rewcd t aQng4 g 1 e4 0.Q Addr (AI b r, City I ] CbC- Zip4 3 "L Phone# 1137-1944 <br />C-57 Contractor U3 Address Cit��C-,Un3ip�Z�# ZC�IO4phone# -1-I� -4loy <br />%-7'�/� i�5 6oz <br />Consultant / Sub Contractor FMC- ll C--r-Q it�Ylr)q Address 2-2BS re ItQAW Cit �Lic# 2Phone# <br />, y�L <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW <br />\ <br />a WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ' DESTRUCTION (choose type below ) <br />0SOIL BORING # DYER -BORE <br />`j*VELL #�A�/LyT` RESSURE GROUT <br />Q' <br />`Other: CC �� Grout Specifications; <br />V <br />COMMENTS:LeL Ko'b?L►uZ J'EX- I.Lk� bx O , 1),,-,T � M�i w l-1� o. I &j, -I s V?S i W 1 I kCC �,I e <br />.-) <br />I <br />. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING [] HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? IJ YES [] NO WELL CASING DIA: <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL [] PVC []OTHER: <br />P <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS [] HOSE <br />[] AIR SPARGE PUSH POINT GROUT SEAL PUMPED: [] Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: <br />[] OTHER: [] OTHER APPROX, BORING DEPTH [I BOLTED TRAFFIC BOX or [] STOVE 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 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 Californi State Laws. <br />Signed x 7�� /�f ///c <br />Title/Company <br />Print Name 7C4 /" ///c/T, Date 7/�tl/�/ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: '3 - a) <br />Application Accepted By. <br />Grout Inspection By <br />Destruction Insnection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />SOS SL�Ut �, vr, /GOP <br />Issued .5'' 2.2. <br />Date (7116 14 oe Final Inspection By <br />Date 61yle <br />• I r <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER INVOICE <br />35o <br />!q <br />S4 -o <br />C-57 -/ WC ✓-WAIVERP C-57 Letter of Authorization to sign permit ncroac ment oc 9/27/00 <br />r.r_t SFJ � <br />600-1� HiAIA 0T :60 T©0Z/ST0 <br />