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I , <br /> WELL PERMIT APPLICATION r'ORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 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 andlor 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 /> Q/ - / ` , c _ 1 \ + p Assessofs <br /> WELL Location OnnIIIDlt7o �pou�.�ellt AnPot�Yraar..� UdCross Street&)La.cO WCA �t6` i\ty c� Zip 5 It7 Parcel# <br /> PROPERTY Ow//n'+er&]Jgt � 1Ygi L IA .C/bCw`vkrlAddress �t �oC1(i'n `uh nK,,1�Cily 54 FANLSIZipgg5?3Phone# 5nnZ5'$� 2�ic.S3" <br /> C37 Contractorla �0.i11' Address_ �tZi, � City '•1 iA Zip TgS53Lic#164gV1 Phone# 7 � 31� SS10 <br /> Consultant / Sub Contractor +�'CrJ Address30�1 ILiI,cSf2- '*'(Q City Lie# (6414% Phone# <br /> GIs Coordinates: X , Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL ! BORING ( CPT, GEOPROBE, HYDRO UNCH, HAND-AUGER, OTHER') U DESTRUCTION (choose type below) <br /> /C&ZOIL BORING # D OVER-BORE <br /> 1) WELL # n PRESSURE GROUT <br /> 'Other: Gmut. Specifications- <br /> COMMENTS- <br /> TYPE <br /> pecifications-COMMENTS:TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING p HOLLOW STEM DIA. OF BOREHOLE L^ 3 ' MULTIPLE CASINGS? p YESZkNQ WELL CASING DIA: kVA <br /> U EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESSIJ/l4 TYPE OF CASING: [] STEEL ❑ PVC [JOTHER: <br /> VAPOR U MUD ROTARY DEPTH OF GROUT SEAL 4A TREMIE TYPE TO BE USED: ]] AUGERS p HOSE <br /> U AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> n <br /> 'SOIL BORING [I HAND AUGE GROUT SPECIFICATIONS: CerwF,v. - <br /> U OTHER: HER k%f W- r APPROX. 13ORING DEPTH [I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> R V CONDUCTOR CASING PROPOSED? Q ( if YES, list specifications here): <br /> •COMMENTS: 6bizin5S rh osis e- Jak <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 1 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. i <br /> Signed KKiH Title/Company �GSQt S 'c �'T <br /> Print Name Date 17.101 <br /> 01 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : ) // <br /> Application Accepted By ��I�( Date Issued Y,6 1 Area r <br /> 13 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK # RECD BY DATE [PERMIT I SERVICE REQUEST # INVOICE <br /> 8ci 3t� � �le o® abof90 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br /> co 39vd N00-13 HIAI3 ££ 17£89b601 TE = ET 0092 / t70 / Zi <br />