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„WELL YLI <br /> ERMIT APPCATION F:64M SITE <br /> MITIGATION . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH,DIVISION (PH.S-EHD) <br /> 304 E. Weber, Third .Floor, 'Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED application is made in compliance with Sari <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the vrarit described. Se <br /> ASsesSaes <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Div�s�on. <br /> Zi Parcel# i <br /> WELL Location 80�I C2,w o/I 5 Cross Street . ”—City d fi p <br /> 0 <br /> PROPERTY Owner �i G [l�� o��pddress y� foc C-Ec zip <br /> Phone# q_q�, 2 <br /> CitS <br /> C-57 Contractor OA go o�rc� (���' Address�•d•!�x- <br /> , Citv_E�0 V _(S Zip4457f Lic# lop Phone# o - O <br /> Pnone# - z2-f <br /> �vlc AddressI ". -� City Sfo Lic#�� <br /> Consultant!Sub Contractor 4 <br /> Range Section <br /> GIS Coordinates:X Y ,Township <br /> wo BE PERFORMED• a DESTRUCTION(choose type belcW) <br /> EW WELL BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER") OVER-BORE <br /> [�SOIL BORIN # j]PRESSURE GROUT <br /> ELL# <br /> Grout S¢ec'sfications: A - <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL IN TYPE CONSTRUCTION SPECTIrCATI MiJLTIPLE CASINGS? YES NO WELL CASING DIA: Z+ <br /> MONITORING - o HOLLOW STEM DIA.OF BOREHOLE <br /> EXTRACTION [1 AIR HAtNMER1DRIVEN CASING THICKNESS S O TYPE OF CASING: U STEEL 9, jj OTHER: <br /> ` VAPOR �J �]MUD ROTARY DEPTH OF GROUT SEAL 2 TREMIE TYPE.TO BE USED: 17 AUGERSHOSE <br /> [�AIR SPARGE Q PUSH POINT GROUT SEAL PUMP?=D: , Yes 1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />_ GROUT SPECIFICATIONS: F o <br /> []SOIL BORING {]HAND AUGER OLTED TRAFFIC BOX or [I STOVE PIPE <br /> OTHER- OTHER APPROX.BORING DEPTH (oS S <br /> CONDUCTOR CASING PROPOSED? 00 (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENED INRp c S. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HO ikS IN ADVANCE FOR ALL REAUIR <br /> oaquiny. <br /> I hereby certify that l have prepared this application and that the work <br /> will be ia Sate Laws done in accordance with,Sat <br /> County Ordinances, Rules and Regulations, and all applicable Calif <br /> TitlelCompany 6C ! <br /> Signed x Q <br /> Date <br /> Print Name DEPARTMENT USE QNL-Y <br /> SITE MAP IN UNIT iV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> e-. Date issued <br /> C Area <br /> Application Accepted 6y a Date 1 <br /> Grout Inspection i3y <br /> Date l I Final Insaecticn By <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID* INVOICE <br /> PECODES ODES <br /> FEEINFO <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# <br /> Z . <br /> r o o �- [ <br /> � 3 as <br /> S 27� <br /> S O dor 9/ <br /> 3 � <br /> C-57 WC^-WAIVER_•.^ C-57 Letter of Authorization to sign permit Encroachment <br />