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S30iA WELL PERMIT APPLICATION FORM <br />Hl�ld3' ! .' i <br />1002 Z 0 11' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />Il 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br />a�G1 1 (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />kpplication 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 />ioaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Olvision. <br />LL Assessor's <br />HELL Location �lJ �3 S Q S % Cross Street �N�� �`k u,y City SraK7by Zip 47,5-20,5'Parcel# <br />IROPERTY Owner GAL re ANS Address 1776 E C -k tR IV -11, _City=N?z:C721V Zip 9SzaS-Phone# Zo 0 i' 8 - �A-.3 <br />57 Contractor% d -W 9!d/`u v Address / y dvA Y / 6 City ���7y�vzip 9y6tit Lic#, 72 phone# 9/6 777- y loo <br />:onsultant / Sub Contractor Address City Lic# Phone# <br />;IS Coordinates: X , Y , Township Range Section <br />MORK TO BE PERFORMED: <br />NEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />1] SOIL BORING # 'AVER -BORE <br />1] WELL # M w - / y PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS; oG W4r-4/- <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />*OLLOW STEM <br />EXTRACTION <br />p AIR HAMMER/DRIVEN <br />] VAPOR <br />[] MUD ROTARY <br />;] AIR SPARGE <br />Q PUSH POINT <br />] SOIL BORING <br />(] HAND AUGER <br />i7 OTHER: p OTHER <br />'COMME <br />CONSTRUCTION SPECIFICATIONS <br />D[A. OF BOREHOLE/ O " MULTIPLE CASINGS? I] YES ](NO WELL CASING DIA: LLQ <br />CASING THICKNESS -rck' 4 o TYPE OF CASING' []STEEL JPVC []OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS WIOSE <br />GROUT SEAL PUMPED: $Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />GROUT SPECIFICATIONS: N� T p�vtTG Ati� C!a'w►�i ✓7` w/ .T fi LSOvvp,V, ; G <br />APPROX. BORING DEPTH ICC;' gcgOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTS CASING PROPOSED? A)V (if YES. list specifications here): <br />NnTF- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL KhQUIKLU I140rr-L. t tvtvQ. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordin"961 Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />.�V <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Title/Company_ PRaZ7�--e <br />nate <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: I I jeL®� r <br />Application Accepted By Date Issued 11 S_ I C7 Area <br />Grout Inspection 6 AIA Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECDBY DATE PI -RMI E0UEST 0 INVOICE <br />35� g .cc G�452F, ��( II 15 G �CZ�D Z <br />C-57_, WC= WAIVER_, C-57 Letter of Authorization to sign permit ooc merit doc, 9/27/00 <br />Z-�� <br />5 <br />( <br />`m <br />kA <br />