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I -di <br /> WELL*&MIT APPLICATION FO SITE <br /> .SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MI ,IGATION. <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Uhl#T IV <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNPAHLE 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 Joaquin County Public Health Services,Environmental Health Division. <br /> '300n'300N C. 5 <br /> Assessor's 1 <br /> WELL Location • G e.i'"�d1ac�[� HuCross Street City 'I'Ot-k1'UYl Zip Parcel# <br /> PROPERTY owner cX .Qt Acity S-+ c l CA 4pg crs rt r ► r. <br /> tisstcc <br /> C-57 Contractor G'r J .��.�a Address qS0 IFowc. Reo�1 Cityjlf�g� 7,,Zip 9yss3 Lic#isZ�torl Phone#975�313�'Eoo <br /> Consultant/Sub Contractor: �Z L RyStX, 1 n Address 117 1 Lo ne.P..��. Z3 City oc1 eS-to Lic# Phone# ? - 2 I <br /> GIS Coordinates:X Y ,Township Range Section <br /> C TO BE PUMBIPED: <br /> EW WELL RIN CPT,rgEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(chpose type belcW) <br /> SOIL BORING# jF,7. Q OVER-BORE <br /> Q WELL# Q PRESSURE GROUT <br /> -Other. Grout Specifications: CC- V-3( <br /> COMMENTS: <br /> TYPE OF WELL INU&LATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA.OF BOREHOLE n MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA:1_ <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS Al A TYPE OF CASING: Q STEEL Q PVC Q OTHER:_ <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Ves Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: f1 OTHER APPROX.BORING DEPTH !901s!5_- Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE.I30ROW 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 Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Sigma X Title/Company 'T C_ <br /> Print Name t.0. r4&ti Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> lication B <br /> APP Y Date Issued 00 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destructlon Inspection By Date !4 <br /> COMMENTS/cONDrwNS: <br /> x � � <br /> [ACCOUNTING ONLY: AID# FArtE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE 0 . 00 Z 0 <br /> C-57 WC -WAIVER C-57 Letter of Autho �zati ign pe mit Encroachment doc 9/27/00 <br />