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0 H�+� <br /> ✓� L WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> V ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> '16457 S. l6anta Kill . Assessors <br /> WELL Location Cross Street Ci rrlC <br /> tY_. _Zip Parcel# 1$Z-D-]d-04 <br /> PROPERTY Owneer Glenn Levine Address 26457 S. I&AMtA tAClty rZtG Zip Phone#22i5-4-5t 03 <br /> f4 <br /> c-57Contractor4sinn Sanr(i» Address1400 S.$0'$ St cityQid""OrAzil, 4804Lic#63638 Phone#51a-237-4515 <br /> —� ,}` �l,l <br /> Consultant/Sub Contractor�eOMdrl-A CRnSHI{Ar}tAressl�M4' NIAiNst. StQ ZI . <br /> n � L�ty CLgD Lic# 601450 phone#559-164-Z53$ <br /> GIs Coordinates:X ,Y ,Township S 2 B'WRange Section <br /> lU 5 Ea!Lt- 3t, <br /> ORK TO BE PE MED: <br /> NEW WELL/ ORIN CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THEW 0 DESTRUCTION(choose type below) <br /> EXSOIL BORING# 4- -S -IV NI5 bps S . DOVER-BORE <br /> 'Other: <br /> f'HYi W- Cbt-Q 0 WICloe Grout Specifications:ELL# 0 PRESSURE GROUT <br /> COMMENTS: Soil berfngs fiw grX6 Ira" WAftr SnnMpliveq <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 'A-V MULTIPLE CASINGS?0 YES VNO WELL CASING DIA: <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ?QA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALI rr TREMIE TYPE TO BE USED: 0 AUGERS �eOSE <br /> O AIR SPARGE PUSH POINT GROUT SEAL PUMPED: pYgs allo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: 1 BY IOwtQ Z 3 CsYn"i- W j �o bO.NtONitQ dp�- <br /> D <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH IF) t BOLTED TRAFFIC BOX or []STOVE IPE <br /> CONDUCTOR CASING PROPOSED? NO (if YES,list specifications here): 141A <br /> 'COMMENTS: <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 application and that the work will be done in accordance with San Joaquin <br /> County Ordinance Rules a d R ulations, and all applicable California State Laws. /' <br /> Signed Title/Company JQAI0r N {1QX.►� / 6e4K-At'4x <br /> `r <br /> Print Name e-e" We 1Y1q Date 2&0 I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, nD SS: <br /> WORK PLAN DATED: <br /> Application Accepted ByDate Issued � Area[U/�W'�Q <br /> Grout Inspection By -Date_MSd Final Inspection y Date %S'OZ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: (- <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED C ECK RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1oi 84 ' 8�t - 6 Ap- I 1121P/ I RR# 002s8-72 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />