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1 <br /> WELL PERMIT APPLICATION FCoZNI SITE <br /> MITIGATION <br /> I 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 <br /> i <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 9.1 115.3 and the Standards of San Joaquin County Public Health Services, Environmentala Health <br /> Division. <br /> AsseWELL Location ZO Bs � MONT SX Cross Street C_ AQ& 4 City SToc.PfVm Zip Parcel# 14h11Z - 03 <br /> PROPERTY Owner _ r� Q ) IEoPP / AN0 Address aj$b P9k54j Mr gayo[Gity Si3tk-roN Zip Phone# 933 Y373 <br /> C-57 Contractor <br /> T iJ R,ep -Address P 'O Box 33 _aty la /S7/A Zlfl 7�Llc# 007 Phone# 7c7 $7Y y <br /> Consultant / Sub Contractor A!qG A O<(A'rEf Address 1117 111 PALM Cityj&k" To Lic# Phone# 2' Zz <br /> GIS Coordinates: X <br /> Y , Township Range Section <br /> WO K TO BE PERFORMED: DESTRUCTION (choose type beloy+) - <br /> EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') OVER <br /> 0 SOIL BORING # _ 0 PRESSURE GROUT <br /> R<VELL <br /> Grout Specifcations: <br /> 'Other: . <br /> COMMENTS SHc LWNA Wox9totAio REV /sE )> .3r%�i0y f E�v� NeENr SC or/ <br /> TCP OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> gFM' ONITORING OLLOW STEM DIA. OF BOREHOLE) p Xo„ MULTIPLE CASINGS? YES �'M1l0 WELL CASING DIA:�Z <br /> 0 EXTRACTION [1 AIR HAMMER/DRIVEN CASING THICKNESS fY'// 4o TYPE OF CASING: 0 STEEL �/C BOTHER: <br /> [1 VAPOR p MUD. ROTARY DEPTH OF GROUT SEAL 1 *RLE TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: eas 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: [I OTHER APPROX, BORING DEPTH APPRDR 7"SwIZS r t7 aOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED91r o . ( if YES, lists, ' icati ns here): <br /> 'COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR E R C NT ERMITS . <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE ORA QUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared t application and that the work will be ne in accordance with San Joaquin <br /> California State Laws. <br /> County Ordinances, es an Re ations, and all applicable <br /> Signed Title/Company, I TC <br /> Print Name NC Date 9�L !Vo <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : L0 t 45C LI <br /> WORK PLAN DATED : <br /> Date Issued ! 1 / S /0Y Area 61111` <br /> Application Accepted By ( /I t, Date I 0 <br /> Grout Inspection By A s �w� Date ( ( O Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> rc � o oz " <br /> chment docs 9/27/OG <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_, Encroa <br />