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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH bIVISION (PHS-EHD j <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatlon is hereby made to San Jcaquin County for a permit to zonstruct and/or install the work described. This appGcatlort Is r jade in rmpliance with Sar. <br /> :oaquin County Development Title,Chapter 9-1115.3 and tt.e Standards of San Joaquin County Pu Ic Hearth Services,Envirer rental'r.eal:h Division. <br /> Asssssar's <br /> WELL �Locatlon_ ie�2 �GeAd , CrossStoet City ��� z _Parcew�tl�l-Q5�1,3 <br /> PROPERTYOwnx IWr� FIIW, _Address 43ZZ_E66e C;ty C _Zp SlkL� Phos.&# <br /> C-57Contrac!cr�) ) �ri�ILAI�Adcress City le Zp.C66t{) Lc#1Z0c�O4F- (91Q737-UIUV <br /> Consultant I Sub Centrrctor e Ad&ess1l l U VtklLm S�i�CGty6&j&,A L..ic+ Phere± - <br /> GIS Coorcinates:X_.... ,Y ,Township Range °crtr <br /> WORK TO BE PERFORMED' <br /> FIEsI WELL t ECRiNC(CP GEOPROEE,HYDROPUNCH,HANC-AUGER,OTHER-) C GES 7 RUCT10%(c`,00se type below) <br /> a SCIL BORING x a OVER-SCRE <br /> WELL# YVL t 10 E PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> rr <br /> ONf'ORING 0-'OLLCW STEM CIA.CF BOREHOL G_6"MULTIPLE CAS NGS? D Y=S N Y1 L CASING DiA: Z <br /> a EXTRACTION li.AIR HA%IMER,'DRIV=N CASING THICKNESS SCI. QQ T)'P=OF CAST\G 0 S7=--=L )I FVC G OTHER: <br /> n VA'OR XtUJ ROTARY DEPTH OF GROJ i SEAL 10 TREUIE-Y( E TO BE USED' GAUGERS ,KH:1SF <br /> p AIR SPARGE Il-JSH PONT GA.O'JT SEAL PUVPc0: ayes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORiNG 0-1A,4:AUGER GROJT SPECIFICATIONS: �J� U L14A+ fnJtr beA 4MI,4f <br /> p OTF-ER: C CTHER A=PRCX.BORING DE.=ITH 1Y)i V=GLTEC TRAFFIC BCA or 0 STOYE PIPE <br /> CONJU(-,TOR CASING PROPOSED?AES('f YES,Ii S:SDec.t)caticrs he•e).G. nS4eel`'' S(avf Shoe <br /> 'CCMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION3. <br /> I hereby certify that I have prepared this applicati . -and that the work will be done in accordance with San Joaquin <br /> County Ordi anc ,R es and Regulatio , nd all applicable Callfornia State Laws. L / <br /> Sigriedz TitelCompany C ST Grp �U <br /> Print NameP.1 U`e L Dats U I �1 10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: > r^ <br /> Application Accepteo By 141:7 1\ Date Issued <br /> Cro.rt Inspection By Date Final Inspes.1oonnBBy � Cate <br /> Destruction:rcoecticn 9y Date <br /> COLdb1ENTS I CONDITIONS: C V'ZU/ l <br /> ACCOUNTING ONLY: AIDq <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DOTE PERMR!SERVICE REQUEST 0INYOICC <br />