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WELL ,�ERM1T APPLICATION _RM SITE <br /> - -- MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT N <br /> (!--J�l 0 9 ?001 ENVIRONMENTAL HEALTH DIVISION (PH ) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> :. (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> don is made in the work <br /> Appl catiCois unty Deve Development Ttie Chapter 9-1115.3 and theor a Standards of San Joaquin t to construct andlor l County Public Health Services'Environmental Health ICivisianNrth an <br /> JoaquinrrAssessor's <br /> ��� L T. city � ��� rp Sq > Parcel# <br /> WELL Location " < lnic� rj, Cross Street(�Gtk S <br /> /f tJcsr t Address i D So City S- C 14), Zip1S�OS Phcnef�ay`�� /�y-i � <br /> PROPERTY Owner 0.f S+ L` RC <br /> �� <br /> \ -s iT✓ Address �Sb ni>r� l� Cityn�Z Zo--y SS c#�iSloLlD7Phon <br /> C-S7 Contrar or \(-/b7'� <br /> Phcnei�.ZQ/ 1 � <br /> Consultant/Sub Contractor /—i G Address <br /> Range Sectcn <br /> GIS Coordinates:X ,Y Township <br /> WO K TO BE PERFORMED: DESTRUCTION (choose type below) <br /> EW WELL/80RING(Cr'T,GEOPROBE,HYDROPUNCH,tjPND-AUGER,OTHER') OVER-SORE <br /> SOIL BORING# o;,) Cr (ec r� PRESSURE -ROUT <br /> (1 WELL# Grout Specifications: <br /> 'Other. <br /> CCMMEVTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS WELL CASING O1P n/�17 <br /> a MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ��. MULTIPLE CASINGS?Q YES a NO <br /> TYPE OF CASING: [j STEEL d PVC a OTHER: <br /> EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS F CASTEMIE TYPE SBE USED: o Q HOSE <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Yes U No (NOTE: MA <br /> XIMM Fr'� -FALL D pT30'� <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS: �b SC�Ck �Di� <br /> �� C01 <br /> G OTHER: D OTHER APPROX_BORING DEPTH �•S BOLTED TRAFFC BC <br /> X or STOVE PTFE <br /> CONDUCTOR CASING PROPOSED? A_(if YES,list spec:ficatians here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRE] INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San aquin <br /> County Or inances, Rules Regulations, and all applicable California State Laws. <br /> TitlelCompany <br /> Signed x 1O A <br /> Print Name �J�I Ci✓� / '(` '�Q�1 _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ <br /> WORK PLAN DATED: O er <br /> Date Issued 1� Ilb / <br /> Application Accepted By l Area <br /> (ice AA�r,� Date i t U o <br /> Grout Inspection BDate 2D d Finaf Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMTr/SERVICE REQUEST# INVOICE <br /> 3S0 �6�j . 00li IGS :LBS <br /> n permit Encroachment aoc_ 9/27/OC <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sig <br />