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WELL, ERMIT APPLICATION Ft- M SFE <br />MITGATICN <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNI T 1V <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 0 �)VEo <br />(209) 488-3449 ll v <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 2 2 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ao lic;W�*�q is made in ram iiartca with San <br />Joaquin County Development Title, Chapter 9-1115.3 and. the Standards of San Joaquin County Public Health Services, 1=4i1r @Optai Health Division. <br />p <br />Assessor's <br />WELL Location 7 Cv �t' G.6 -r_ Cross Street rCaty <br />n p <br />PROPErZTYGwner !� Gn` (,iC�V^/eI/t Address l %,A �lU i%Vh':ir-ty�r;Zy'�%Cly �p�JYI�'r7 <br />--r <br />C-57 Contra or�V1 iii-��Ur;1 I� C� Address j[:U 5 tr l V:1G7Zip � i� L 1jc# (? Phone/�� <br />C� 1 `7�JYUt2 <br />Cansuitarrt/Sub Contractor -,Kd Address �3 5 >� tG�<,u �'(J� C:tyC•�"( J��, UdF��I�? ��F!�cn ,t �% (�%/�'t� - <br />GIS Coordinates: X , Y , TownshiQ Range <br />Section <br />j] SOlL SCRING '(] c. � - <br />a OTHER: II OTHER APPROX. SCRING DEPTH ' 0' i % CL i c7 TRAF=iC BOX ar (1 STOVE FIFE <br />�n CONDUCTOR CASING PROPOSED? �� L` (if YES, list specifications here): <br />*COMMENTS: t I V �7 1 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTICNS. <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 />/ T <br />Signed x ✓�.E -H l I� Title/Company J <br />'J i Dat <br />Print Name , I i lir <br />nFPARTMENT USE ONLY <br />SITE MAP IN UNIT 1V FILE, ADDRESS: v"Dai Se <br />WORK PLAN DATED: ��•�lii "v �` ;�� <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection BY Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: — <br />ACCOUNTING410INLY:AID# <br />PE CODES <br />WORK TO BE PERFORMED: <br />EW WELL / SCRING ( CPT, GECPRCEE, HYCROPUNCH, HAND-AUGE.R, OTHE.R') DE57RUCTiON (choose type below) <br />V� <br />v� <br />REC'D BY <br />p SOIL BORING # <br />Q OVER -BORE <br />INVOICE <br />WELL # �, 1,.'5 <br />.r 1 i ✓ 0 PRESSURE GROUT <br />ZZL <br />'Other. <br />Grout Specifications: <br />CCMMENTS: <br />TYPE OF WELL <br />,KMCNITCRING <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS /I <br />DIA. OF SOREHCLE o ,>'t 1. MULT1Fa� CASINGS? [] YES .$ WELL CASING D1A� a 6 <br />STEM <br />a �AGTION <br />,,*HCLLCW <br />❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS _CC i. Y( TYPE OF CASING: a STE: L �<PVC [] OTHER: <br />VAPOR <br />MUD ROTARY <br />DEPTH OF GROUT SEAL. 3 fj?ef TREMIE TYPE TO BE USED: �GE.RS Q HCSE <br />Q AIR SPARGE <br />Q PUSH POINT <br />GROUT SEAL PUMPED: 11 Yes�N, (NOTE: MAXIMUM FREE -FAL- DEPTH IS 30') <br />AUGrR <br />r- io;,� !ILCHAND <br />GROUT �PcC1F1CAT10NS: �I y��riC�i: rOrl%��,t CC 4� <br />j] SOlL SCRING '(] c. � - <br />a OTHER: II OTHER APPROX. SCRING DEPTH ' 0' i % CL i c7 TRAF=iC BOX ar (1 STOVE FIFE <br />�n CONDUCTOR CASING PROPOSED? �� L` (if YES, list specifications here): <br />*COMMENTS: t I V �7 1 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTICNS. <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 />/ T <br />Signed x ✓�.E -H l I� Title/Company J <br />'J i Dat <br />Print Name , I i lir <br />nFPARTMENT USE ONLY <br />SITE MAP IN UNIT 1V FILE, ADDRESS: v"Dai Se <br />WORK PLAN DATED: ��•�lii "v �` ;�� <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection BY Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: — <br />ACCOUNTING410INLY:AID# <br />PE CODES <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P 5T # <br />INVOICE <br />ZZL <br />.. 1-1-7 inn <br />C-57 WC! WAIVER C-57 Letter of Authorization to sign perms t ooc____ 7/ C-1 i W- <br />