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I WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> 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 /> - NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> Application is hereby made to San Joaquin County Por a permit to construct and/or install the work described. This application is made <br /> Health lance with San - <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Enviro2.05 nmental <br /> Assessors Division , <br /> �t r)A) city SToC ao ro Al Zlp qs <br /> WELLLocatlon `AUP4 / All? Cross Street�R <br /> PROPERTYOwner Ty c{ 51VCK 6: Address <br /> 1(2 ;5 ) • eL jb0g,40 ;iry 57 7i7N Zip Zo 2.Phone#- <br /> ' ^ D n RnY ? 2 Clty Yo /S?1 ZiP7L"�1'—Lic# DD] Phone# 7a7 37� y <br /> C -57 Contractor ' ^'' ' • t R,Qp -Addresses-----. -aq <br /> Consultant ) Sub Contractor A" 'f( Ar r6 S _Address " ' "� � 7� E PALS City <br /> 'h� Yu Lic" Phone# 4E <br /> Y <br /> Range Section <br /> GIS Coordinates: X_� Townshlp� <br /> WO WKTO BE PERFORMED: 0 DESTRUCTION (choose type belV) <br /> OVER-BORE <br /> EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER' PRESSURE GROUT <br /> U SOIL BORING # - <br /> 54ELL #J ' � <br /> Grout Specifications: <br /> Other LAa v / V + A nIE SIN E.�T S [ D7 <br /> COMMENTS SCC W G70F/ f RE !SE <br /> al <br /> TYp OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> CASINGS? o YES o4o WELL CASING DIA:- Z_ <br /> ONITORING OLLOW STEM DIA, OF BOREHOLE 9 —/O <br /> U EXTRACTION Q AIR HAMMERIDRIVEN CASINDEPTHGTHICKNESS !DCk 1/0 <br /> OF GROUT SEAL AAL PE OREM EI TYPEOTO BE USED: 0 GERSR 0 HOSE <br /> VAPOR H MUD ROTARY <br /> ❑ AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ees p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: s"lZS , <br /> APPROX. BORING DEPTH aAOdO�y �OLTED TRAFFIC BOX or p STOVE PIPE <br /> U OTHER: II OTHER . �� �� if YES, list specifications he e): <br /> CONDUCTOR CASING PROPOSED? 142 <br /> 'COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACH P ITS . <br /> CALL THE UNIT IV INP 11 SPECTOR 48 WORKING HOURS IN ADVANCE FOR <br /> E NSP CTIONS . <br /> I hereby certify that I have prepared t s application and that the work will be don in acco ante with San Joaquin <br /> County Ordinances , MeS and Re ations, and all applicable California State Law^r <br /> Title/Company e5 . / <br /> Signed z Date /Z y0 7 <br /> Print Name � � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : dfs o ^ — LL ` p / C, <br /> WORK PLAN DATED ' o; ^ 4- � � "` I <br /> - � � � Area <br /> Date Issued <br /> Application Accepted By Date <br /> O <br /> Date t `' Final Inspection By <br /> Grout Inspection BY Dale <br /> Destruction Inspection By <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODER FEE INFO AMOUNT REMFFrFD CHECK # REC'D BY DATE PERMIT/ SERVICE REQUEST # INVOICE <br /> 9 Sit , L I I S o` { o zs6o <br /> 3TO I tSel • O9/27, <br /> C-57_ WC=WAIVER_. C-57 Letter of Authorization to sign permit_ Encroachment docs <br />