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FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 100Z S 0 A01i ENVIRONMENTAL HEALTH DIVISION (PHS-EHID) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 <br /> PION-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to sw Jolquin County far a permit to conetruct and/or instal the wade described. This application is made In compliance with San <br /> Joaquin county t3aw-lopment Title.Chapter S-1 1162 and the Standards of%n Jcraquln County Public Hearth Sorvi�,En%rironm.tntz1 Health Dlyizim. <br /> WELL Locatlon-13qql IJA" Ctv= <br /> M lwlaA�snrls <br /> — <br /> PROP2RTY Owner VG)nPtn `CS. <br /> Addram D . (�O7( k C) <br /> C'57 C.ntra CID r.Wke Add,,=�3 <br /> ConeuXuar;I Sub rt7]nQI1-eAAkU2 VO. Qty_ UcP*a) PhD.-# '-IL <br /> GIs coonlinares:x—,Y Tawnahlp Range Section <br /> ;r <br /> w:� 50LI BORING(CPT,GEOPROM HYDR H,HAND-AUGER,OTHER') <br /> R 1]DESTRUCTION(dIocso We Wow) <br /> 2�SO1LEIORjNG#_1Tqr- 11 OVER-SORE <br /> 11l I rjWELLA- T� 11 PRESSURE GROUT <br /> a�*,g --Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WEU INSTALLATION TYPE CONSTRUCTION SPECIFICATION <br /> [I MONITORING A*iCLI-OW STEM DIAC)FBQREHOLE-EL"--muL'ripLreAsiNG52uyEsamo wELLrAGow.-P <br /> 11 EXTRACTION [I AIR HAMMERIDRIVEN CASING T1-iICKNF35620. TYPE Cf CASING: U STEEL <br /> [IPVC 11 OTliF1i: <br /> U VAPOR 0 MUD ROTARY DEPTH Of=GROUT SEA4,_ -�y,(J ' TREWS TYPE TO BE USED; "UGERS 0 J10SP <br /> U AIR SPARGE El PUSH POINT GROUT SEAL PUMPED: I]Yes :ffNo rNOTF— MAXMUM FREE-FALL DEPTH IS 3o') <br /> S�SOIL BORING fl HAND AUGER GROUT SPECIFICATIONS: -j-- <br /> 13 OTHER:---------0 OTHER_ APPROX BORING DEPTH �af' aBOLTS TRAFFIC BOX or USTOVE PIPE <br /> CONDUCTOR CASING PROPOSED?- k& (if YES,hst3pecifimfions 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 REOUIRED INSPECTIONS. <br /> I hereby rartify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordl 7n Rut and Regulations,and all applicable CaliforniaStale Laws. <br /> Signed x —TiWCc,,nPn 6 <br /> Y. <br /> N1 <br /> Frint Name t^ Vito L-r-C Dale DEP.ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2"398 z—tI ONLY// :!Z� <br /> WORK PLAN DATED: <br /> Appticativn Accepted By, Bala lwued_ <br /> Grain Inspection By IFInal wxpecson By Date <br /> Dedruction I nrcn By Date <br /> ACCOUNTINGONO'. A404 PXV <br /> PF CODES FEF INFO AMOUNTnrmm=CHWKS RECD BY DATE PERMIT/SERVICE REQUESTit <br /> I V /7'1-A- sw <br /> C-57� WC -WAIVER C-57 Let-ter of Authorization to sign permitGrEncroachment dcc_ . 9/27/00 <br /> ZO 39Vd 1,101ACCIS 39V G111L9760z 09'VI TOOZ/TZ/TT <br />