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WELL PERMIT APPLICATION FORM <br />looz s 0 /Wig SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ORIGINAL <br />SITE <br />MITIGATION <br />UNIT W <br />Data Issued /7/12" /61 Area <br />Date Date <br />Date <br /> Final Inspection By <br /> <br />APpkG3tidn Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />. NoN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made ti San JOaquin County for a permit b construct andfor instal the work described. This application is made In compliance with Sari <br />Jo,atarin County Development Tale, Chapter s-11152 and. the Standards of San Joaquin County Pubic Health Services, Environmental Health Division. <br />WELL Loc=tion:23 CIEel )J. OttA.K01 Gross SaieeticiAtiCileCir V/ 1 City Zip cf al....p Parcel# <br />Assessor's <br />PROPtNTY Owner kre.-0\41t91.2* VAA.0(-a_ Address V: 0. PAK ka city \._..)..,, zip15-2:10..fh...# <br />. 403 <br />C-.57 contractor .,13es4T Erx_lt‘AAXIL..bic Address L¼p4 1/2- Cit)t-1.4414444,VP5-51 II? LlaSS4etift Pricio=o <br />Consultant 1 Sub Contractor AP11.2.46Cotrq .ke.. Ortftles_ . 1337 SVIAIL1 ‘Aci City c...)4. _L./Alegiv7-7 Ph.ea kit:7 —I <br />GAS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />.1cNEW WELL! BORING ( CPT, GEOPROPE, HYDROE'UNCH, HAND-AUGER, OTHER') DF_STRUCTION (choose twe below/ <br />4-SOIL BORING # -s" (,„ El OVER-BORE <br />WELL# U PRES:SURE GROUT <br />_ Grout Specifications: <br />TYPE OP WELL INSTALLATION TYPE <br />a MONITORING ..1K1OLLOW STEM <br />EXTRACTION AlR HAMMENDRIVEN <br />a VAPOR MUD ROTARY <br />a Alit SPARGE Ii PUSH POINT <br />ASOIL BORING f] HAND AUGER <br />0 OTHER: ___11 OTHER <br />"COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />01A. OF BOREHOLE I;i; 4 ` _ MULTIPLE CASINGS? n YES ANO WELL CA,SING DIA: 444 <br />CASING THICKNESS AA_ TYPE OF CASING: U STEEL lj PVC U OMER: <br />DEPTH OF GROUT ZEAL 7_0 TREMIE TYPE TID BE USED: OcAuGERS Li HOSE <br />GROUT SEAL PUMPED: p Yes NW° Mrc:AXINIUM FREE-FALL DEPTH IS 30') <br />CI -GROUT SPEFICATIONS: CIP-4&04.-A4- <br />APPROX BORING DEPTH U BOLTro0 TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? A.42 ( if YES, list specifications here): <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 />I hereby certify that I have prepared this appiition and that the work will be done in accordance with San Joaquin <br />County Ordit6ies,RuIsf and Regulations, and all applicable California State Laws. <br />k"),*2,-Ct-C..1g11 0-1fAiltlakk a4t Gkeioollvt41,- <br />-Daig 11 _4,00 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE. ADDRESS: 2395z _zti 44t,,,/ <br />WORK PLAN DATED: <br />.0thir ktn t.41 or\ a kinL or COMMENTS: <br />Signed x slitteiCompany <br /> <br />Print Name CAkii Le <br /> <br />COMMENTS I CONCIMONS: <br />, ACCOUNTING ONLY-. •-, <br />1 <br />.... <br />AID# FACIA Da'? C3cR_fr a <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE . PERMIT f •,". '. - INVOICE <br />--- / FY ;$ S-9 3--q7 Cf.-it- SR# /..--72-6 7 <br />C-57 WC --WAIVER c-57 Letter of Authorization to sign permit Dt. Encroachmsnt doc - 9/271°0 <br />17,{1 NOIA001S 39V <br /> 8TITL906@Z 05:PT 'MK/7M