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i <br /> • FILE COPY <br /> WELL PERMIT AP FORM <br /> UO QUIN COUNTY PUBLIC HEALTH SERVICES SITE <br /> JAN 14 2004 ENVIRONMENTAL HEALTH DIVISION PHS- MITIGATION. <br /> ENVIRONMENT 304 E Weber, Third Floor, Stockton, C EHD) UNIT IV <br /> PERMITjSERVI�ESTH (209) 468-3449 A, 95202 <br /> VPllcation is hereby made to San Joaquin Cou <br /> nty-for aUN�DABLE PERMIT <br /> Joaquin County Development Title,C <br /> Permit to mnstru EXPIRES 1 YEAR FROM DATE ISSUED <br /> hapter g-t 1 t .3 and the Standards ct and/or install the work described, <br /> NELL Location \Z S of San Joaquin Coun p This application is made in com liance <br /> W G T� Cross St S, tY Public Health Servioas,Environmental Health p,y�s�pwl San <br /> PROPERTY Owner�4o Ca a reet_Arq°rq-t Clty STo-IL*o CISZ.D Assessor's inz7 °'O¢ <br /> l Address O(� S, 0� S Zrp�b Parcel# m-3 <br /> C57 Contractor �b' w p2.,, p City cLtS Zip`)S3S 1 <br /> r Addr s t0 �ZPhone# 52,=_ <br /> Consultant Sub Contractor �w`a 4_�r� Qv�C `��City `LS_ 4}a.�Lp I°V1ULogpy <br /> ST Phone#�1�. L)IDO <br /> GIS Coordinates:X Y City m t'�As�JUc# <br /> Phone# <br /> Township <br /> WORK TO BE PERFORMED: —��Range--�Sermon_ <br /> A NEW WELL 17'C.TG;CPT,GEOPROSE,HPDR PUNCH,HAND-AUGER,OTHER-) " <br /> 0 SOIL BORING 1]DESTRUCTION(choose <br /> "Other, A WELL# Q I 3 type below) <br /> 0 OVER-BORE <br /> COM - ' Grout Specifications: 0 PRESSURE GROUT <br /> t to; '' r cl L O 2 ' S <br /> TYPE OF WELL L gLLATION TYPE <br /> 0 MONITORING CONSTRUCTION SPECIFICATION <br /> OLLOW STEM DIA,OF BOREHOLE <br /> XTRACTION)L,L,t. 0 AIR HAMMERICRP MULTIPLE CASINGS?0 YES 0 NO WELL CA�NG DIA: <br /> 0" yED: CASING THICKNESS TYPE OF CASING: 0 STEEL PVC <br /> 0 VAPOR /�,,yI�UD ROTARY yr � DEPTH OF GROUT SEAL ❑OTHER: <br /> 0 AIR SPARGE l YPYJSH POINT CrAl TREMIE TYPE TO BE USSSED:. 0 AUGERS 0 HOSE <br /> V/ GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:�I�QT <br /> a OTHER: tl OTHER APPROX BORING DEPTH_ 2 r <br /> o /' Q CONDUCTOR CASING PROPOSE-D 0 BOLTED TRAFFIC BOX re 0 STOVE PIPE <br /> �EOMMENTS: 0 !, fttTt4 Q —17 — AX <br /> (If list Specifications here): v <br /> sa' — <br /> NOTE: OFFSITE BO IN S 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 a plication and that the work will be done in accordance with San Joaquin <br /> County nanc s, ujes d Regulation ,and all applicable California State Laws. <br /> Signed <br /> Trhe/Company <br /> Print Name to Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 12-Y:5 &A <br /> WORK PLAN DATED: 0—Q <br /> ApPlintion Accepted By Date Issued ��0 <br /> Grout Inspection By -Area <br /> Date Final Inspection B Date <br /> Destruction Inspection By Date C— <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED C ECK# RECD Y ATE PERMIT I SERVICE R6QUeZ_T41 wvoice <br /> D3 <br /> doc <br /> C5� ttec o`t Author\zntiortt°sg"pQ1'm`��Encroachment _ <br /> ��`�` �� - Egbg89b60Z 9S t6� <BBZ/BZ/Z0 <br />