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U <br /> WELL PERMIT APPLICATION FORM <br /> . . . _ SITE <br /> r l <br /> LJ JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> Ii <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> SLP 2 0 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> Com/ W <br /> • .. AR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YE <br />'. Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This <br /> Joaquin County Deveiopment Title,Chapter 41115.3 and the Standards of San Joaquin County Public Health Services, is made n compliance with San <br /> �I Health Division. <br /> WELL Location��/J�� lYc-'sn4e Cross Street Clh, Zp o7 ParAssessor's <br /> PROPERTY Owner gdd <br /> ress(,� St(1 <br />" Vattor A�l�� _Z rte^��^'?'�City ZP PhortEPl��Q <br /> C-57 COn $378ir+b <br /> � AddressPG,�n 3,76' cty�sG.f�. zp9vs7/ uckN,'7?Phone*2!737y14,gm <br /> consmtant/sub.6eatrastor 1,e4> n a •E Address /.?86E de/»�Sf city Gre - 61�ic#Sl,38S7 Phone# SabO <br /> GIS Coordinates:X Y Township ,Z/l/ <br /> Range AE Section 2/ <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER•) gbESTRUCTION(choose type below) <br /> 0 SOIL BORING# e - OOVER-BORE <br /> 'Other. P'WELL# tXe.<-Sr hi RESSURE GROUT <br /> COMMENTS: y)jwsa:// b- pArr (��,f 4 /yjli Grout Specifications: 3f� �rkrle�s./ ! 5�10 Oen Ln <br /> me -111 br 'zo,-bore <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?DYES D NO WELLCASING DIA_ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 1]PVC 0 OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 0 Yes 13 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or D STOVE PIPE r <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina es, fes lations,and all applicable California State Laws.. <br /> Titla'Company Ii' _�pea«v/G(iei',�«. C4. +�,p. <br /> Signed x <br /> Print <br /> t/DEPARTMENT USE ONL�Y��,,p <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �G t ZS 11 ^� ` <br /> WORK PLAN DATED: _d <br /> Application Accepted By Date Issued 7 ! <br /> Grout Inspection By Date Final Inspection By / <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> I <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE - PERMIT I SERVICE REQUEST# INVOICE <br /> 3sD2 W� too 38 8 Cit A 4-� <br /> r-r17 Wr -H/ATVFD r-ri71 o++or n4 A„+hnri,n+inn+n cin" nerrni+ FnrrnnrL,rnen+rdnr Q/27/0n <br />