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WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <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. Z.J <br /> t' ''/ /� Assessors <br /> WELL Location A[I <br /> y/J � A/u $T.', �.1nnr-tcA Cross Streetl�l/tTMDAE City /�wurEaA Zip9S33L Parcel# ,7/9- <br /> 7d7" <br /> PROPERTYOwner _ Ci , GAAjr1eA _ ipyr3hon- - o3Sl/ V Lg <br /> C-57 Contractor r C�reS t</t -$i _Redress 9610 /I/OWL IaAD City 2r7U1 _Zip l D hone# 9aS- 313-SYoO <br /> / Itt �lewt. wscr u+4cct <br /> Consultant/Sub Contractor amim,¢ Lam 7"-14"_11.�1Mt- Address Svoro x CityS��Lic# Phone#J056 23y-e5'4' <br /> GIS Coordinates:X Y ,Township 2 S Range E Section 7 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> SOIL BORING# 3 Cf rI3 NYWAItlya14 0 OVER-BORE <br /> WELL# •Z [I PRESSURE GROUT <br /> 'Other: Grout Specifications. jj4Ar djA#XA -r <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE lojl MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA:07�M <br /> EXTRACTION I// Q AIR HAMMER/DRIVEN CASING THICKNESS Sa.k,. NO TYPE OF CASING: (I STEEL VC p OTHER: <br /> 0 VAPOR 1]MUD ROTARY DEPTH OF GROUT SE..-,L_9 TREMIE TYPE TO BE USED: AUGERS p HOSE <br /> a AIR SPARGE �J PUSH POINT CCpr� GROUT SEAL PUMPED: xYes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING / 0 HAND AUGER GROUT SPECIFICATIONS: ,11241- &A4tV r- <br /> 0OTHER: Q OTHER APPROX.BORING DEPTH 30�' Slo��as. BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Ala (if YES,list specifications here): <br /> "COMMENTS: A&WIM& Wza 1ijsrALLArTON k• eKmAcrlo" llWtLG /&usrAt4ein N sire 1.'jytsr7AAr'7o0U <br /> ryR ��nJDwillt�Z Sy+�►Pc,t s �CPr'//�ySH Au[vr) ON£ a" 3D-Fool wEct� GN �n yo-I-oorwt Es< IZS�CPr <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT9. t30121"'6- PA" <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 Ordinanc s RUI and Regulations, and all applicable California State Laws. <br /> I ��L <br /> Signed x <br /> Title/Company �il2n'/ GN'ya�hl <br /> Print Name �i <br /> &Hll I!RJ [ f Dates Gs�.d .2DD3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / <br /> Application Accepted By—Av �•` " ate Issued O L 1 ���Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# ��r [' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R CID DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 f �q.0 ' 0 5 <br /> =7 %./l• %A1AT%iCD r-;;-71 0++o.• „f Ati+h i7ntin n ainn narmit Fncroachment doc 9/27/00 <br />