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a <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SRN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DiVISION (PHS4EHD) UNIT IV <br />344 E. Weber, Third Floor,Stockton, CA.., $5242 <br />(209 ) 468-3449 1 <br />6wC �N-s <br />NON-REFUNDABLE PERMrr EXFIREB I YEAR FROM BATE SSUED <br />l,,plic-.`.;�rt is hereby :Wade to Syn j v.Qv7n Countf for a install t`:e work dsscribed• This application is Trade in compliarro with San <br />,o qu n County Q ;ve{oprnent'fiUe, Ghtipter 17 1$.3 and the Standar`-. of $aar oaquln County Public Health Servires, Envir r nmenml kotaith Division. <br />,455 eSSpr s <br />WIELL Lucaticn s - -� - _ _:Dross Street G^, &Vt�e City, <br />FROPFF"n, Ownea C_�L Co / �l `[C f ; dOress 3P 46-e( (Ilf [ tci. /L (V <br />C -5T C•natn3ctor 6-S Ca-w-� — ,A�+ddret e2 ce>ec- CCrCl� city . D I c S10�r one l6 � 'i4' 11 4 <br />S,onsul:ant I Sub c;,� :tractor ��'r /4 �/�Y`r� ,address C X ZZe, 14klh, � Cl T �� I Ic# % Phone# <br />---�-- ---- — —s- <br />C;s Coo ;r:aces: X _- _ Y� Township__ Range' — Section <br />WORK,, T,7 C'- FEo.FORMED: <br />^IEOI V:'ELL I ACIR!NG (CPT, GECPRORE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />I] SOIL BURINC� <br />'Cnher; T - Gr.utSpeeifcatiorsi <br />COMMENTS - <br />a DESTR JCT ION (atioose type below) � <br />[I IOV2R-BORE <br />I] PRESSURE GROUT Z <br />O <br />N <br />"Vk^E C:F W:t--L-E WST,ALLA,?0N TfPE COItiSiFZi. CI ON SPECIFIC TIOWS rc/ r <br />p,M1t1Nl?ORIiJG NOLLO'vV S fEtV. DIA. OF BOREHOLE — Mlli TIPL I~ C7 11tgPS i Q YES NO GVELL CASING DfA; / U1 <br />GXP'.CTl01v 9 AIR Hard114'EFTIRIL'EtJ CASING THICK*dESJ� J'YP,E�.7. F CA: ING: 0 STEL -L PVC Q OTHER: <br />9 MILID RO', ARY DEPTH O GROUT S'eP! .J -C TREMIE i"wr^E TO BE USED: $AUGERS L HOSE <br />j,? AR SPARGE F2 POSH POlivT GROUT SEAL PUMPr_ - tO "es &Nq A10TE: PdlA)(lMUM FREE -FALL DEPTH IS 30) <br />S' Si7iL aOR:NG 0 HAND "WO— R Gft04T SPE_ii=!CP.T1C7V5: �i �"�' <br />.^7HEr _ APPROX. BORING DEPTH PL 357 OLTEO TRAFFIC BOX or p STOV5 PIP= <br />"COM <br />CQNUU-_T'�R CASING <br />, list specifications here): <br />NOTE: OFFSITE BORIINGS, REQUiRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT fv! INSP'ECTO+R 481iVORKING HOURS IN ,ADVANCE FOR <br />1 hereby eami :Ify that I have prepar&d this application and that the wort£ wiII- be c <br />County C.' frdin#AcgS;4�uiea and Regulations, and all applicable Calltornia State <br />Signed <br />Prin' Na� ��' <br />SITE MIP IN UNIT I!i• PILE, <br />WORK PLAN DATED' <br />App'.4;aton Accepted <br />Grout !nspecti.mt Ly_ <br />Dcstract!on insoactic <br />COM. N1cNTS 1 <br />ACC(-UtiTIN(- ONt,Y: 1, A-!!x� <br />DEPARTMENT USE DNL <br />�(osov S..T�0 Ire <br />Date_ _ Fins' InsperAm By <br />Date <br />REQUIRED INSPECTIONS. <br />in accordance with San Joaquin <br />r,CC1t7� <br />FEE INFO j A1VOUN REMIT -F-.`3 <br />CREC'K # 4 I3E�'D BY <br />DA[- <br />I RERMIT t SERVICE REQUEST # i INVOICE <br />C<57 ✓ WC. ✓ _WAIVER__�­ 7 Letter u" Aut1'!orizuf icn to sign permit ✓� Encroachment doc— 9/2 7/00' <br />i <br />