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Q r I <br /> TION FVr i SITE l <br /> WELL P�MIT APPLICATION <br /> SAN JOAQUIN.COUNTY PUBLIC HEALTH SERVICES . ; - <br /> ENVfRONMENTAL HEALTH DIVISION�(PHS-EH p <br /> C �`',!� �n� Stockton,��CA:, 92 t 61 �1 E U . 304 E. Weber, Third Floor; <br /> (209) 468-3449 <br /> MAR 0 s zoos <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROMrDATd I This application with <br /> ?• Joaquin County for a permit to construct a anf r suint County Publithe work c Health Servics, nironmental Health IDivi�n San <br /> 4ppli �c�' �' ,Chapter 9-1115.3 and the Standards of S 4 Assessor's <br /> Joaquin rC� � Zip .SZoZ Parcel# -Z3D <br /> 0e C�j Cross StreetCity .5rd ;7L <br /> r <br /> WELL Location rpt <br /> Cf 5+ OZip Zl—1P h a n eA P3- <br /> �+U S Addressl�tLY�nrtet r ,VimL tY <br /> PROPERTY Owner a YJ.�tic bj Phone#t - <br /> 30 <br /> Address �' A✓ C� Zipr1 <br /> C-57 ContractorPhone# 7�0z' }�6 - - <br /> city� _Lic# <br /> Consultant/Sub Contractor� > UkRW--Address$ s��� 3 — <br /> Range Section <br /> GIS Coordinates:X <br /> Y Township r <br /> rNEP <br /> K TOBE PERFORMED: 0.DESTRUCTION(choose type below) <br /> W WELL/BORING(CPT,�EOPROBE•HYDROPUNCN,HAND-AUGER,OTHER") [j OVER-BORE <br /> LB <br /> BORING# jI PRESSURE GROUT <br /> `�W <br /> WELL <br /> # out specifications: <br /> *Other-. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC WELL <br /> dd <br /> Y !/ <br /> lI MONITORING )(HOLLOW STEM <br /> DIA.OF BOREHOLE 0" �r MULTIPLE CASINGS?0 YES �NO WELL CASING DIA:7 Z <br /> Alft HAMMER/DRIVEN CASING THICKNES D TYPE OF CASING: n STEEL APVC a OTHER: <br /> aXTRACTION D MIE TYPE TO BE USED: AUGERS " 1}HOSE <br /> E GROUT SEAL TRE <br /> VAPOR ❑MUD ROTARY DEPTH OF <br /> E 0 <br /> PUSH POINT GROUT SEAL PUMPED: Q Yes ANo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> II AIR SPARG <br /> jI SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> ! <br /> i1 OTIiER:_��II OTHER <br /> APPROX.BORING DEPTH .3 � <br /> CONDUCTOR CASING PROPOSED?_; (if YES,list specifications here): <br /> �! <br /> ! .W <br /> 'COMMENTS: <br /> �lD <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEIV� �PNRp oNs. <br /> CALL THE UNIT IV 1N5 <br /> PECTOR 48 WORKING HOUR <br /> IN ADVANCE FOR ALL REQUI <br /> I' I Hereby fy that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County din c I nd gulations, and all applicable CaliforniaState Laws. <br /> r Title/Company it <br /> Signed x - P <br /> / �� Date <br /> Print Name Aub �• DEPARTMENT USE ONLY <br />` SITE MAP IN UNIT IV FILE, ADDRESS: <br /> k I <br /> WORK PLAN DATED: y <br /> Date Issued "" " Area d <br /> Application Accepted By Final trispection By ate <br /> Grout Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> l CHECK# EC' Y DATE PERMIT I SERVICE REQUEST# <br /> PE CODES FEE INFO AMOUNT REMITTED INVOICE <br /> �O ,.o� doc - . 9/27/00 <br /> C-57 WC -WAIVER C-57 letter of Autho ati gn permit Encroachment - <br />