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WELL PERMIT APPLICA i IUN I-UKM SITE <br />I TION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) IV 1111) CCS <br />304 E. Weber, Third Floor, Stockton,�� � � <br />(209) 468-3449 I <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />• pn i5 heresy pace to San joa^uin Coua. for a permli 10 constriJcl anCip' Fnsia!I :he :vcrf desCflcr�. T.'.is ap, iica;.cn is made,- :- -: 'iance'.v :h San, <br />A'noli a. 4 <br />n Co�h1y Cevelp^ne t Tae, Chapter .•t t 15.3 and :he Sanda �s of San Jca;,_�n County P�o1ic -ea::h Sen ces. E^: rr-Te-:a: 1+alt^ Ci✓sio,. <br />n <br />Joa ,u Assessor's <br />vrELL Location 1910 Country Club E?- • _ _ Cress S:reet Mission _Civ Stockton zea-Parwt=nkknowrn __ <br />PROPERTY Owner�yyt �I pCtpL' yL r•ni11Add•ess Ifl/O e.. 6--e.ZA-! &CIry Sbocktc_n• --z'a 95ACLcne- <br />C -s7 Corl ac!or V.W. 2.11ing Tr2 AdCress P.O. Pox 51 C 1y33i� Vi --ta_zi;)44571 L.c= Ph:,, -)e= 707 X74-2815 <br />Consultant/ Sub Contractor WeSteM Geo-517,ineerSAcdress 186 E. Parer Ci:y � Li:,- 513857 Pno-e? 530 668-5300 <br />GIS Coordinates: X _, Y To,vrship 1N Range 6E Seccn <br />WORK TO BE PERFORWIED: <br />NEV! WELL / BORING (CPT. G_OPROEE. ri,YCRCPUNCH, HAND -:AUGER. OTHER') � C=S -R CT O� (:-::)Sc- qpe Belo.) <br />SCRE <br />OIL 50R!NG = T -2 rl FRE SURE <br />�jYELL Mf.7 Co 0 PRESSURE GROUT <br />-other: Groot Spec!1cations: _ <br />CCD AIMEN T S: <br />D± OF WEtL.. <br />INSTALLATION TYPE <br />5WONITCRING <br />]<HOLLOW STEM <br />0 XRACTIC', <br />DAIR HAMrtZR/CRIV=N <br />Ij VAPOR <br />0 MUD ROTARY <br />(j AIR SPARGE <br />0 PUSH POINT <br />.SOIL BORING <br />[j HAND AUGER <br />0 OT! -.En: <br />_0 OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOR_HOLE_ �ff ML;'LTIPLc CASINGS? 0 YES K\O 1'rE.L CAS;NG D:4_z_ <br />CASING THICKNESS 5�6 S/O TYPE OF CAS;NG: 0 S -EEL [] 07?- R:_ O <br />CEPTH OF GROUT S -=A!-_ _Lg TREII!IE TYPE TO 3= ScD: ;j .JGEF�S �iCSE <br />GROUT SEAL PUMPED: jKYes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30`) <br />GROUT SPECIFICATIO\sS neat cenent 5% ialtmite <br />APPROX. BORING DEFT 30' ;K60LTED TRA== -C E: X or 0 S T OVE P:=E <br />CCNDUCTOR CASING PROPOSED? nO (it YES, I'st spec f:ca: cns here). <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED IN5PEGTIONS. <br />I hereby certify that I <br />County Ordinarnne� <br />S:gned x <br />Pini Name z6eorKe L. <br />ave prepared this application and that the work will be done in accordance with San Joaquin <br />�IeS f�pr�,Iatinnc and all applicable California State Laws. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: '/6-(0-00 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS J CONDITIONS: <br />PARI <br />Date <br />Date <br />9e/company westPrri Cina2r-- <br />Cate 1 --1 <br />F USI UN <br />ate Issued —/.3-0/ Area U p <br />inal Inspection By <br />Ln/,- 32- -Ce- <br />ACCOUNTING ONLY: AID: <br />PE CODES FEE INFO AMOUNT REMITTED CHECK x RECD BY DATE ! SERVIC <br />C-57 WC -WAIVER C-57 Letter of Author!zeticn to sign perrnit oechm! <br />--- F•'._I_ Ec`EE:rt Z. <br />E3 .5:-c ''-- - <br />e <br />INVOICE <br />9/27✓a0 <br />