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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 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 /> /� Assessor's <br /> WELL Location I�ETttoRE C1r�A! rJ7 ttCross Street W4,A) City ,,l4yr-t!:A zip J6734 Parcel# <br /> Bt+Bua ea wny <br /> PROPERTY Owner 401ry bF .444,�-ze-4 Address /oo/ W, ejer rc/Z Sr: City Af 4jlrLCA Zip 9533 Phone#el49-?39-Srr/4U <br /> I„ S i"-4 Cg33ofr2 g5" <br /> C-57 Contractor 'ilel66 Address 960 awt ;?PA O City .t Z171Vt Zip_2q ' 3Lic#��Phone#`)iIS 313"Sroa <br /> /Yt fRAMIC WAST 0*44C <br /> Consultant/Sub Contractorausoe ftrt/7f /LtN..&Z..Address .Fur Ti t CityJr70tCr0A) Licff Phone#(2,0-f)t39-of r <br /> GIS Coordinates:X Y Township d S Range i�,x Section 7 <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 5 /{YDjlDPUA,74M 0 OVER-BORE <br /> 0 WELL# (I PRESSURE GROUT <br /> 'Other: Grout Specifications: 661A'r �tatc AjT- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a?" MULTIPLE CASINGS? 0 YES JNO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL N/4 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE ?/ PUSH POINT - CPT GROUT SEAL PUMPED: 0 Yes �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING / 0 HAND AUGER GROUT SPECIFICATIONS: .volt L°1.N1"7— <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH a?S r 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AIA_(if YES,list specifications here): <br /> 'COMMENTS: .f/TL J,�vrsn�.�no.) ` %USN P4jAj 13O/Q11U6-S A&A, ri12dtjAj0WATLQ SAmri f S <br /> NOTE: OFFSITE BORINGS 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 Ordin ce Rules d Regulations, and all applicable California State Laws. <br /> Signed x '�/� . Title/Company &&,)DJA �.ft2� �lGlfiVOL06'rt S �Iyc• <br /> Print Name zA4- ZC1A7G Dy5/LE tr�� Date OC;&,QtR •�03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By - � u V Date Issued D <br /> + <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FArtg <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C' BY DATF PERMIT/SERVICE REQUEST# INVOICE <br /> OSR# <br /> f 52'L <br /> c� %Al/- %A/ATI/CD r-F7 I o++or of Allthnr•17ntlnn to ¢inn nv.rtnit Fncroachment doc 9/27/00 <br />