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ORIGNA-L <br /> WELL PERMIT APPLICATION FCMM SITE <br /> SEP 2 G Z001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> Efv`Jih�01T/SE i I-,E_ES H 304 E. Weber, Third Floor, Stockton, CA., 95202 �t / <br /> f Ef3l`�11Tj5Er��.�'IrES (209) 468-3449 0A wb <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 JoaquinCounty Public Health Services,Environmental Health Division. <br /> Ass <br /> WELL Location _CY25 Ar-r4'L �l�enve Cross Street 1)"g1w ✓/City S�r�Y�cr/r Zip9r�7 Parcei#�sors <br /> PROPERTY Owner�ir7�li/n /'k ��ieS Address,�7�{ Lirl�/n 0elY�^ City /-47� Zip 95.07Phone#20 94V,7-_711 <br /> C-57 Contractor6y( &J Qf,///nth/+ Address I'•G [.rte City Ui)Ya Zip Wkl�'ArPhone# 2V A010 <br /> Consultant h6 s�tceetOr�CJ M Lr����piNrG3iAddress /�� ,� >K jf• City i/ /Lic#51-7857Phone#gg� - 0 <br /> GIS Coordinates:X Y Township---2 Al Range 6 Section z/ <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) v `I <br /> 0 SOIL BORING# ,VOVER-BORE <br /> WELL#y/1Lao7, ML4,3 {yew/ IhwYedwl _10 RESSUREGROUTT <br /> 'Other: rout Specification: YXQ,4Mx 17 <br /> COMMENTS: /c.(krt /JVG fc44Me../o oeoo, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES []NO WELL CASING DIA: T� <br /> 0 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 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE i <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): 1 <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 s, Rule d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> (,. O <br /> Print Name ��� ( 1����'� Date- <br /> SITE <br /> //DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ` �` 'y Area <br /> Grout Inspection By Date Final Inspection By e <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# 2 Z <br /> /-_F7 \Alr _\A/AT\/FD /'_ri7 I ottor of Aiithnri7ntinn to <inn normit Pnrrnnrhmont Anr O/27/nn <br />