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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PIiBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH bIVISION (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)s hereby made to San Jcaquln County for a permit:o construct and/or install the work described. This application is r jade in compliance with Sar, <br /> ,Ioaqui-i County Develcpment 71.1%Chapter S-1115.3 and tl.e Standards of San Joaquln County Publlc Health Services.Envirar rental F eafh Division. <br /> ���``..'••__,, ffcc Assessor's <br /> WELL Locatlot_I�SSS �out.�( CrossSLoety�f)) S7(e¢} Clty(-Zr�,, Z:p_% ParCeM <br /> PROPERTY Own\_ LfM <br /> 'rVAf1_?X,t_U Address Z� City Z'p�—Phone <br /> .�L. <br /> C-57 Contractor V LlJ kIiA dcress IQQyS` S•}e12� City Lpg5C t1 L:cT77ASU4 F,o 416)ill•41[b <br /> onsultant ubContractorC_M1,,jJ cru Address111U /bolt/ Sk4e2L- Cityfs U::# Phene# <br /> GIS Coorcinates:X .. ,Y ,Township Range SeG�r <br /> _., <br /> WORK TO BE PERF0RS1Ec <br /> NE-01 WELL r 2C�c!F1C{CPT,GEO?P.OBE.HYCRCPUNCH,t-ANII-.AUC-R.OTHER-) �,DESTRUCTiO`,(chooss type balow) <br /> (] E <br /> LE, RE <br /> SOIL BORING;; SURE <br /> WELL#� sic V WtT1�3 E,PPRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE gONSTRUCTION SPECIFICATIONS of <br /> Q MONrrOR1NG ,'-10LLCW STEM DIA OF BOREHOLE ID MULTIPLE CAS NC <br /> S7�Y.S Q NO WELLCASINGDIA:�, : <br /> []EXTRACTION f,AIR HAMMERDRIVEN CASING THICKNESS 5c1% Lib TYPE OF CASING. o STEEL XFVC G OTHcR: <br /> jA,oOR 0 MUD ROTARY DEPTH OF GROUT SEAL _?Q-P--4 TREMIE^!-E TO BE USED: *UGERS 0 H:rSE <br /> f]AIR SPARGE fl=JSH POINT GROUT SEAL PUMPED: res p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (1 SOIL BORING 0-LAND AUGER GROJT SPECIFICATIONS: NX tk Cewili '"I Solt <br /> 0 OTFER: [I;,THER A=PRCX.BORING DE?TH 4Z )K30LTEC TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? At.) (:f YES.lis:spec:ncatiens here): _ <br /> 'COMMENTS: %vnmvt S .S VEWL C" S�a 26%= <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNfT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby cert) tha ve prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or na ea, yes and Regula tio , and all applicable California State Laws. <br /> Signed x Titre/Company SVrt�'1 <br /> PrintName Al U.Eu'eK Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 `6-9 y-f T�� - <br /> WORK PLAN DATED: ML,4 1417-oo <br /> Application Accepted By Date Issued Area <br /> Crout Inspection By ( A,. ' Date It Final Inspec:lon By Dale I t L d <br /> —7 r <br /> _Destn.ctien!nspecticn 3y Date <br /> COMMENTS!CONDITIONS: - <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT ISERcVIICE REQUEST# INVOICt'_ <br /> 350 g9-oo 011l`I � Ir o/ C) 57- <br />