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WELL ERMIT APPLICATION FCI@M SITE <br />TION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />UNIT A <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) n <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 MAY 0 6 2003 <br />NON-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 WftAUH <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. E <br />` p Assessor's <br />WELLLocationd �� 1 1 ,�1�1 - Cross Street � �Q��City -! ltr Zip Parcel# L 'O <br />PROPERTY Owner: llY MMkT t"CkMD Address Ci �l Alra Zi cffly�Phone# <br />tC <br />Ill 3� It L09 <br />C-57Contracto 6 ddres (��� �1 i Ci 0�-Zi� 01LIV Phone /� <br />Consultant /Sub Contracto ddressb'7 J1 I�Ii�iP Citt 01._ Lic# Phone ` 1 i�P 14lbb <br />GIS Coordinates: X <br />, Y Township Range Section <br />Gnra <br />WORK TO BE PERFORMED: <br />PE CODES <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />AMOUNT REMITTED <br />CHECK # <br />B SOIL BORING # 0 OVER -BORE <br />DATE <br />PERMIT/ SERVICE REQUEST # <br />0 WELL # 0 PRESSURE GROUT <br />'Other: <br />Grout Specifications: <br />COMMENTS: <br />� 2L v <br />SR# <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING <br />`-a-f-IOLLOW STEM DIA. OF BOREHOLE `rJ MULTIPLE CASINGS? 0 YES>. -NO WELL CASING DIA:lt/ <br />7�� <br />0 EXTRACTION <br />+ham' <br />0 AIR HAMMER/DRIVEN CASING THICKNESW`i//��`T�TYPE OF CASING: 0 STEEL�PVC BOTHER: <br />C!!)0 <br />VAPOR <br />0 MUD ROTARY DEPTH OF GROUT SEAL t) - L j ;)�__ TREMIE TYPE TO BE USED: 0 AUGERS �16OSE <br />0 AIR SPARGE <br />0 PUSH POINT GROUT SEAL PUMPED:�e 0 No (NOTE: M IMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER GROUT SPECIFICATIONS: K <br />0 OTHER:_0 <br />OTHER APPROX. BORING DEPTH - BOLTED TRA IC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMENTS: <br />— — <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />`1 <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify <br />that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County O At a <br />es, Rul - d Regulations, and all applicable CaliforniaState Laws. <br />') <br />Signed x <br />`Title/Company <br />1GI p yr VXOr--xY\111 tAA -, Harp � I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By LjRDate Issued r �/— <br />Grout Inspection By D Final Inspection By <br />/ l'cK <br />Destruction Inspection By , Date (1 , , i <br />