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WELL PEKNIIT APPLICATION FORM SITEMITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS -EBD) <br />304 E. Weber, Third Floor, Stockton, CA., 95242 <br />(209) 468.3449 <br />ON -REFUNDABLE Pt=RMrr EXPIRES 1 YEAR FR M D TE ISSUED <br />N <br />tippllcatien is hereby made to San Joaquin Gounty for a permit to Construct andlor install the work described. This application is made in compliance with San <br />Assessors. _c�—I <br />loaquln County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Heal+h Divlsivn. <br />}� L 1 City' I Zip_1— Parcel?f <br />�r� a Cross Street 2"Q <br />NELL Location L f 7 �` Z f /< Phone# 2— iL- <br />T I (2fiTri Address r � vX 3 � � City,= TZ - z P_1 <br />PROPERTY Owner �I �� I 1 <br />V.ry c -c �w . �� Pnone# 2017 - % 7� <br />n t SL P�5'W "' Gc#,r- <br />r J N ER I S Y L- , qty, SI'� _ �---- <br />r ' fires 'Phone C-57 Contractor ii S t N C I I cf �C) i-1 c R+T-.'►L--, i � \_ '(3L'�t� Lic$�! � -� C `�`� 6 <br />�� N Address t A K Ps- �. �City� tr <br />Consultant 1 Sub Contractor Township Range (1 jam,(} + SecLion <br />GIS Coordinates. X <br />Y . <br />R TO SE PERFORMED: DESTRUCTION (Choose type below) <br />yi (] OVER -BORE <br />g NEW WELL 1 BORING ( CPT, GEOPROSE. HYDROPUNCH, HAND-AUGERGD� ER')� M�f p PRESSURE GROUT <br />SOIL BORING <br />U WELL ti Grout Specifications: C <br />►k C . <br />COMMENTS: <br />12 <br />tcficv. <br />INSTALLATION TYPE CONSTRUGnON SPECIFICATIONS YE5 Q NO WELL CASING DIA: <br />TYPE OF WELL DIA, OF BOREHOLE_— MULTIPLE CASINGS. I) <br />13 MONITORING D HOLLOW 57EM TYPE OF CASING: p STEEL PVC 0 OTHER: <br />EX?RACTION []AIR HAMMER(ORIVEN CASINGTHICKNESSf— TF CASTEMIF- TYPE TO BE USED' O AUGERS (] HOSE <br />D VAPOR I] MUD ROTARY DEPTH OF GROUT SEAL— <br />SPARGE PUSH POINT GROUT SEAL PUMPED: D Yes n No (NOTE: MAXIMUM FREE -T=ALL DEPTH IS 30' <br />a AIR i <br />HAND AUGER GROUT SRECIF{CATIONS: <br />I0,SOIL BORING a APPROX. BORING DEPTH i BOLTED TRAFFIC ons or p STAVE rtPE <br />u OTHER:__—[] OTHER — — if YES, list speciFcat;ons here)' <br />CONDUCTOR CASING PROPOSEOT,—_ <br />onolntrS REQUIRE ACCESS OR ENCR0Atrrlmr-1%f^ ucc�rTloNs. <br />NV 1 F: vrr�a.... —.. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANC <br />certify that I have prepared ALL <br />this application and that the work will be done in accordance with San Joaquin <br />I hereby Y livable California State Laws- <br />County Ordinances, Rules and Regulations, and all app G ��C, rs r �iyE,I.vE <br />` Title/Company <br />Signed z `IL <br />Print Name 1 C K ' H( c DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:: <br />WORK PLAN DATED: <br />Date IMUaaj <br />Apptimbon ACcePted By Date i Fnai inspection By <br />Grout Inspection By Data <br />COMMENTS / CONDITIUna: <br />ACCOUNTING ONLY, AID# F <br />RECD BY DATE <br />PER 5T # INVOICEPE CODES FEE INFO AMOUNT REMI'TT ED CHECK # <br />roachment doc 9/2' <br />(:-,57_ yvC� WAIVER: C-57 Getter of Authorization to sign permit, <br />