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I WELJL PERMIT APPLICATION OR SITE <br /> SAN J QUIN COUNTY PU$LIC HEALTH RVIC E MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> UNIT IV 1110 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)'468-3449 M"" tP <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;,poli ation is he?e5y mace to San Jcaq�in Count'for a penult lo.conStruci cn:i0':nVall:he%Sisk�ffiSCri:ems. T.'.is a,^,, 1M.-G'1 i;made. :Jr'l3!iance w:.h Sar <br /> Jo2qu.n on iCDjs e*r"..;rent T:Je.Chapter=•1115.3 and -e St3nda_s of San Jcaq.in County PiDlic�ea::h Se.rvices.=rti=r~'T.e.:2:-Ieztt7 DiVSiaa. <br /> Assessor s <br /> WELL Location. 1'0 Cress S reef 1 S_i O�—_Ci y StOCkt02�Z Par unknown-- <br /> PROPERTY OWner Y Add•ess t Ctry __Z;a- 1--ke <br /> 5t'Cor.Lac:or V.W. I�i]7�I1� Ti]C AdCres/s C;t)�JS a_zip '�LL'c= J Fna,e= 707 7M-2815 <br /> C - <br /> 4 ~tin Ery- ine� �d�ess 1�$6 E. Erne^ CjtyW_adl� Li: 51'7 -Pri�-et; -5300 <br /> Consultant!Sub Convaclor - <br /> GIS Coordinates:X Y Townshia 1N Range 6E Sec:.on 4 <br /> %vr1RK TO SE PERFORMED: D=G'RLC7 0�{-aosE type below)I�EYI 1'�'ELt!9OR!NG T.GEOPROBE,rVCROPU.KCH,HAND-AUGER.OTHER") <br /> ` _ C1L 90R1i`G= GOVER•SCRE <br /> 4'ELL 0 PRESSURE GROUT <br /> •other: :f �GroA Specifications: <br /> comm_NTS: : <br /> TYPE OF W iL INSTALLATION TYPE CONSTRUCTION SPE�I lTiONS N <br /> yG5? }1'ES 'p tY = L C'S\G r:.4 <br /> *m6NITCRING 'HOLLOW STEM DIA.O-BOR=-OLE_�,NL'LTIPL= C1S! . Z <br /> EXTRACTION- D AIR HG,h1tJERlCRiYcy CASING THICKNESS 6 �O TYPE OF CASING: OST EEL = O- ER: <br /> ()VALOR 0 MUD ROTARY Or GROU7 SE.L }1 TREtiIE TYP=_ TO 3E ;SED: °}AJGERSICSE <br /> [1 <br /> AIR c? C fl, PUSH POINT GROUT SEAL.PUMPED: jrYes -,.,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30))SOIL 60nING � - []HAND AUGER GROUT SPECIFICATIO!�5:_I 3t CHIt3l1 5%l taiZte <br /> {}OTHEn:y �d OTHER__j_, <br /> APPROX.BORING DEFTH Or �60:7ED TFRA==,C SOX or a STOV2-P:PE <br /> N CONDUCTOR CASING PROPOSED?nO it YES,i!st saec f_z:pans>•erg}: <br /> a <br /> 'COMMENTS: <br /> NOTE: •OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> s.� <br /> 1 her certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinastc u[es ilat'inns, and all -ppllcable California State Laws. <br /> .� <br /> „yelCpl'npcny <br /> Signed z <br /> Cate <br /> i- n:NEzse �' �"'� pEpARTMENT USE ONLY <br /> 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issc:ed Area <br /> ea <br /> Application Accepted 8t' to <br /> Grout Inspedicn 8t' <br /> Data Final Inspection By <br /> DeSiNdion tnspeaon By Dzie <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID: CAC! <br /> PE CODES FEE INFO AtAOUNT REMITTED CHECK x RECD BY DATE PERMIT!SERVICE REQUEST tl INVOICE <br /> C-57 WC ! -WAXVER C-57 Letter of Authortzetien to sign permit Encroachment doc� 9/27/d3 <br /> L <br /> FILE COPY <br />