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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH bIVISION (PHS-EHD) <br /> 304 E. Weber, Thlyd Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERNIrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Jcaquin Count'for a permit to construct and/or install the work desc rIbed. This application Is r jade in compliance with Sar. <br /> Joaquin County Cevelcpment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public HeaRh Services.Enviror rental HeaLh Division. <br /> Arcetu �7- T`1V"lI 'g <br /> WELL Location_II� L�1,,,I-�l�uw�¢2 �,-tw�C Cross SLoet Z�nu�crw� City S�rz�,� Zp _Farce[#/ , <br /> PROPERTY Ownerep.-I Ilium" _Add ess 1 40 (U�Fim �►t�ue City $ uW Z p Phcnd 7-94S6 <br /> C-57 Contractor gpet.MaM Ey4�n, Adcress 3LS Cy<<Guw+ A/ Ciry$ �v La_ L c IlIGYFn y65 8�/L <br /> Consultant;Sub e ro Add'ess I1t4 ftki-x4 .S'Itt-cA C ty Li:# Phcne# &36-SSkP <br /> GIS Coorcinaies:X Y Township Range SeGtcr <br /> WORK TO BE PERFORMED- <br /> 0 NE01 WELL v i CR NC(CF-.GEO-ROBE, HYDRCPUNCH,[-ANC-AUGER.OTHER) *DES T RUCTION(cd.00se type below) <br /> Q SOIL BORING x 0 O ERd3CRE <br /> J,WELL# ►'1 W(2i n XRESSURE GROUT <br /> -Other. Grout S edfi tions: ILpthc tcxJt Ge►wgj L',I&4ee <br /> Cv'J.t,'ENTS' 1'NW L F, NAw"1 LV U <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING C-10LLCW STEM CIA.OF BOR=HO MULTIPLE CAS NGS-, Q Y=S S NO WELL CASING DIA: <br /> []EXTRRACTICN r,AIR HA RAER'DRIVEN CASING THICKNESS Tl'=E OF CASING GST EEL []PVC Q OTHER: <br /> II vA-OR rJ MUD ROTARY DEPTH OF GPO-11 SEAL TRE;MlE 7Y=1E TO SE USED- U AUGERS Q H:1SE <br /> p AIR SPARGE n-USH POINT GP.OJT SEAL PUV:PE.: [I Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING O.HAN:AUGER GROUT SPECIFICATIONS: <br /> p OTF-ER: OTHER A=PRCX.BORING DEATH 0 30LTEZ TRAFFiC BCA or Q 370VE PIPE <br /> CONDUCTOR CASING PROPOSED? ( 1'YES.lis:spec fications he,-a). _ <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNr 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 MOiane�UleSandgulations, and all applicable California State L/aws.� .";4 <br /> 1Signed x / Tit elCompany O (. 12A o . ;7 <br /> Print Name M'., f J Q u\ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Q n� Cbl DZ <br /> AppllcationAcceptec Byi1�--1 Dare Issued `-! ��I6( Area <br /> Crout inspectlon By Date Final Inspection By Cate <br /> Destruction;rtmecticn 3y Dare <br /> COMMENTS/CONDITION& <br /> ACCOUNTING ONLY. I AfD# <br /> PE CODES FEE INFO AMOUNT REMMED CHECKS REC'D BY DATE PERMIT l SERVICE REQUEST 9 INVOICE <br /> ('-0- i 60 - n!1 02-2- '711-0101 I SM 002-77 38 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/OJ <br />