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M* WELL PERMIT APPLICATION FVr2M SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />��I^ n� _1 ENVIRONMENTAL HEALTH DIVISION (PHS -EH <br />I6 UEC) 304 E. Weber, Third Floor, Stockton, CA., 9520 <br />'l---� <br />MAR 0 8 2001 (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Appli(U46Aj+ jjPLy( pde ? � Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />q V1 I r P1, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Joaquin Vl � I rj L j � Assessor's _ <br />i � ,� -- 3 �U,1 dd <br />WELL Location OQ M U -CV Cross Street �MoA 7 ST.' City S%GLkTGKI Zip752y� Parcel# Assessor's <br />t7 <br />E7 xtlf' A <br />C�UiS� g00 <br />PROPERTYOwner!%D .�EFA¢�C✓ S'&Tl�iESS Address `RtF� �IVi2 bfl- CityS/x TOK Zip Zl1 Phone# %3' 75 <br />C-57 Contractor LTel L DQa14j,(r -Address57&0 S- I'1 KT AiIAE Cit4��zip y2 Licti7giLl Phone#(IJ 3f' <br />30 <br />Consultant/ Sub Contractor ADVAAkip &"W a Address $37 SMW Rom City?eL{Ctrxl Lic#@0227 Phone# <br />GIS Coordinates: X <br />Y <br />Township <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, EOFIR BE, HYDROPUNCH, HAND AUGER, OTHER') DESTRUCTION (choose type below) <br />— 5_ 0 BORING # 0 OVER -BORE <br />WELL # Z. 0 PRESSURE GROUT <br />`Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y �/� <br />M It W <br />0 MONITORING <br />HOLLOW STEM <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:—O <br />OTHER <br />a le <br />-- - — - '' - , <br />DIA. OF BOREHOLE 10 tb MULTIPLE CASINGS? 0 YES ANO WELL CASING DIA. <br />CASING THICKNES U TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br />DEPTH OF GROUT SEAL & + TREMIE TYPE TO BE USED: ArAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: P62t IeI�'� <br />APPROX. BORING DEPTH .37 y BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />r!a V11 / . 71' r^&- Qr. W - /,", • it). tN�� A041 <br />–VA <br />OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRtD INJF'tG I IUIVJ. <br />I hereby .fy that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County O din c , t7/nd regulations, and all applicable California State Laws. <br />Signed x Title/Company i) F <br />Print Name�Aul- � � � bG� Date 03 ' 646^ �� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectic <br />COMMENTS / CONDITIONS: <br />Date <br />Issued <br />Inspection By <br />162 <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />fiEC' II3Y DATE # <br />INVOICE <br />IC <br />C-57 WC -WAIVER C-57 Letter of Auth4 2atiiart �Y-49n permit —Enzr en doc_ 9/2//uu <br />IJ / <br />