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WELLPERMIT APPLICATION FAM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />B A"MNO'�DRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />2pQ5 APR — lflE. Weber, Third Floor, Stockton, CA., 95202 <br />smi K,.�C�L'1Fe COIF (209) 468-3449 <br />EN`11Rt7NNEN7 At <br />NENT <br />AITH 0 nRTHENON-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 r `i CS ,(A M"'I 0, . Cross Street F` OAA ML- - City �c : Zip Parcel# C <br />PROPERTY Owner ,_hevr. i r xq c o � M c- Address IoO c l goj l ijAgr (A ; c., City_? ,t Zip`3 f A3 Phone# `125- 541Z -1572 <br />C-57 Contractor L L 1).^ 1 s Address 3 c 2 0., e,�, L, % I c City�a-deye, Ziph � %yL Lic# 7L 7 ,c Phone# <br />lig G 3� ir�v <br />n ', ,w .l. <br />Consultant / Sub Contractor Sec cr -T, 4e Address 3c 7 K l �. City C>���� • Lic# Phone# `116 J' e / ':`/C'0 <br />GIS Coordinates <br />Y <br />Township <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER <br />0 SOIL BORING # <br />0 WELL # <br />*Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />f(HOLLOW STEM <br />(I EXTRACTION <br />a AIR HAMMERIDRIVEN <br />AVAPOR <br />0 MUD ROTARY <br />,KAIR SPARGE <br />0 PUSH POINT <br />Q SOIL BORING <br />0 HAND AUGER <br />Ra <br />Section <br />OTHER`) DESTRUCTION (chose type below) <br />eVER-BORE <br />y 0 PRESSURE GROUT <br />Grout Specifications:(�ort'u.lc(-+��F"���Or't{�;7,ti<C <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE i1, MULTIPLE CASINGS? 0 YES &NO WELL CASING DIA: Z N <br />CASING THICKNESS tt C TYPE OF CASING: a STEEL 'jtPVC Q OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: `QAUGERS a HOSE Q <br />GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') v1 <br />GROUT SPECIFICATIONS: <br />OTHER:_0 OTHER APPROX. BORING DE <br />a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS:7 6 lJ , ie i l s (11 w- I , �, -2 - y � . � -2 ) � / � / i�> � V w I , L M t � '<, C'Z4­0 ICS- 0 FL <br />des�t��cd <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 />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 />Signed x kiAt,) i V Title/Company L-�-- 5t�' e" kry � 7f i�c)d = -4 <br />Print NameLhc:t _e5 'J4tnrDate / ? �r " l 7r 2 ✓v <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 c\ C S i -�y- � -i 11, s (. <br />WORK PLAN DATED: � I i � 1 cs <br />Application Accepted Byniter' �— Date Issued l{ i G `; Area r <br />Grout Inspection By Date -i -2- afe- N Final Inspection By [_�, ,ver:— Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# eerie <br />PE CODES FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PE # <br />I INVOICE <br />3SO.z 11(,c^ <br />`i rV(' # EC' <br />C�Z <br />C-57-- WC -WAIVER C-57 Letter of Authorization to sign permit Encroac m 9/27/00 <br />W <br />'0 <br />4- <br />