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1 WELL PERMIT APPLICATION TWIVI SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton , CA., 95202 <br /> (209) 468-3449 FILE COPY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> C CUA+y 2 KA- O p , Assessors <br /> WELLLocation 31 `12 ScojrlN F 1 66 ,;c4e Cross Street ILY Qyt- City ��oc,l .+W Zip Lc2 1 Parcel# <br /> PROPERTY Owner CCUf1TY - QF Sti✓� � ct VoyAddress ;2. ,�n eb �- City�Zlp Phone# <br /> C£y ContractorCre e Tr\,,11 S , 1' u Address y� {{nwe I� City_&r] r Z,,,,ipf19E3Uc# �SG? Phone# r1l�aS-3 k3 'S&:G ' <br /> Consultant / Sub ContmctorA u4rr[t2� �uFnu (Cyft iafAddress n7 SLeo. 14X City 5+0(4( ,r1 Lic# 6YOaR7 Phone# / � y - �C6 �' <br /> GIS Coordinates: X , Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 13 DESTRUCTION (choose type below) <br /> 'BOIL BORING # P ' /O - p. OVER-BORE <br /> �1tt <br /> b WELL # p PRESSURE GROUT <br /> 'Other: '2eA 4, Inekex ,r U - G. C) FT EasF a P ML/ 7 Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING (I HOLLOW STEM DIA OF BOREHOLE 2 X A MULTIPLE CASINGS? p YES ONO WELL CASING OIA: <br /> 1] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 11) F T TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE fi ,PUSH POINT GROUT SEAL PUMPED: 0-Yes ]] No (NpQTE: MAXIMUM FREE-FALL DEPTH IS 302) <br /> SOIL BORING OHANDAUGER '� GROUT SPECIFICATIONS: Por-4- Jan ? <br /> O OTHER: [l OTHER APPROX. BORING DEPTH GLS' FT 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ; I CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> 'COMMENTS: C 7p T 41X: (-i e% <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OOrdll/dances, Rules and Regulations, and all applicable California State Laws. r' <br /> Signed ( v+ e Title/CompanyEft renMen ktt /$PeC -u / 'S4//�tcy UArrcj (yep <br /> 5 <br /> Print Name 11r �ple 4 M ler Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : S!/ y7 <br /> WORK PLAN DATED : Z Z08 <br /> Application Accepted By Date Issued O Area ` L <br /> Grout Inspection By Z Date Final Inspection By Date <br /> Destruction Inspection By ! - D�aLte <br /> COMMENTS / CONDITIONS, yr cet �" "%'�7 / I'OZ u' 73 <br /> ACCOUNTING ONLY: AID# <br /> PECODES FEEINFO AMOUN7RE7Mr;rTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> a , �9 SR# Oo2 ?Se6 �! <br /> C-57 WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />