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FtL ' P <br /> h WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> SEP 2 9 2 )0� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> uIvip.(j^!;B,4=ie; r E'L 304 E. Weber, Third Floor, Stockton, CA., 95202 N �T <br /> PERIw'iT/!EF',Yil(;�S (209) 468-3449 !� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> descnbed. This appination is madein conplance with San <br /> Application is hereby made to San Joaquin County for a penny to construct woor imtaG the work <br /> Joaquin County Oe eloPrnent Title,Chapter 9-1111y1JJ5.3 and the Stardards of San Joaquin County Public Health Services,Eneirmmeraal Heath DiNsion. <br /> ^.c,..LfB+e Cross Street �rR/city <br /> fly � 9 z07 Parcellt L2— p!As O'66 <br /> 2-1 <br /> WELL Lxatlon (P1I S �'" as <br /> 77Gb Lp—P. <br /> PROPERTY Owner_ ._ . `' re <br /> C_57 Conaador Ulee4t . 21lCay , Zp957/tc#7�o79 Phone# 17 3;Y*?w- <br /> a� f c 376 <br /> Consultant ls«aca+tactor4,l 'rM -E.r—_Aaaress 13th Q�met Sf cityGGaa✓/o,/dl�c#S/357 Pn«,�! S,,bS3�? . <br /> GIS Coordinates:X <br /> y ,Twvnship 2N Range 4j E SecLm z y - <br /> WORK TO BE PERFORMED: ESTRUCTION(choose type belwv) <br /> G NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER•) G OVER-BORE <br /> G SOIL BORING# PRESSURE GROUT <br /> p1NELL#__ T—T Grcut Specifications:3 f7l mly Hr S% Doh 'f <br /> Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> G MONITORING G HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELLCASING DIA_ <br /> TYPE OF CASING: G STEEL G PVC G OTHER: <br /> ROTA <br /> G EXTRACTION G AIR R/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: G AUGERS G HOSE <br /> Q VAPOR G MUD ROTARY DEPTH OF GROUT SEAL <br /> i G AIR SPARGE G PUSH POINT GROUT SEAL PUMPED: G Yes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> G SOIL BORING 1 OTHER HAND AUGER GROUT <br /> PPROXSBORING�DEPTH G BOLTED TRAFFIC BOX or G STOVE PIPE <br /> 0 OTHER G YES,list s natio s here): <br /> CONDUCTOR CASING PROPOSED? (if P� <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N 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 S, (regulations,and all applicable California State Laws. <br /> TrodCanPanY l/0 gOpeA..oli+' <br /> Signed x <br /> Gs%LB�lf Date <br /> P"ntNane L DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> 1005 LoP. <br /> WORK PLAN DATED: <br /> Date Issued �Q , Arma <br /> Application Accepted ey Date­_______Final Irks a LF 1 <br /> Grout Inspection By <br /> Destnution Inspection By Date �. <br />�• COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35-07- 5'J 8 P <br /> M <br /> r-ri7 WP -WATVFD r-F7 I shfoe oAiitl,nri�ntinn in <inn nsr,n if Fn�rnnrl:rnonl rin� <br /> O/77/ <br />