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a ` t <br /> w WELL PERMIT APPLICATION FORM SITE <br /> Ml T IGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third <br /> 9 468 3449 ton, CA., 95202 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEISSUED <br /> ith San <br /> App y county _ Assessors <br /> lip[ion is hereby made to San Joaquin Coun far a permit to construct and/or install the work described. This application is made in compliance w- <br /> s(� ry C=Zip LIY Parcel#� <br /> Joaquin county Development Title.Chapter 9-1115.3 and the Standard s of San Joaquin County Public Health Services,Environmental Health Division. <br /> G r Ll�.�� � fJ�O�� C I- Cross Street /k""'m��Ci S� 4 Cott -3�J u <br /> WELL Location l�-. P, /1 I.8 t40 city sk-o kl— Zip yS L"l phone# <br /> CA. r Ci <br /> _Address City Q1=Zi y Yj2t Lic#}l�� Phone# -�S <br /> PROPERTY Owners .3�� u� zip <br /> 9q57-1 <br /> Address A �x s}A-LCL I <br /> C-57 Contractor ry /4-j'l+%b Lic# Phone#�— <br /> _ III b— (v. City <br /> Sectionl� <br /> Consultant/Sub Contmctor t �' Y-- Township��Range <br /> GIs Coordinates:X_� a DESTRUCTION(choose type bell <br /> OVER-BORE <br /> WORK TO BE PERFORMED: PRESSURE GROUT <br /> VEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER-) <br /> g SOIL BORING# <br /> 'ZNELL# nw� A-� <br /> Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS O WELL CASING DIA:? <br /> �" MULTIPLE CASINGS? 0YES ) VC OOTHER: <br /> TYPES WELL ��— DIA.OF BOREHOLE�a <br /> �OtONITORING 'HOLLOW STEM TYPE OF CASING: O STEEL HOSE <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS SL�� TREMIE TYPE TO BE USED: . D AUGERS <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> p VAPOR GROUT SEAL PUMPED: V Yes 0 No (NOTE: Nlk REE-FA1-L DEPTH IS 30') <br /> Q AIR SPARGE N PUSH POINT G_wv-� <br /> GROUT SPECIFICATIONS: � �OLTED TRAFFIC BOX or Q STOVEPIPE <br /> 0 <br /> SOIL BORING HAND AUGER c fL t� <br /> OTHER�� APPROX.BORING DEPTH if YES,list speciricaficns here): <br /> 0 OTHER:_- CONDUCTOR CASING PROPOSED? <br /> -COMMENTS: <br /> NOTE: OFFSITE <br /> BOIZINOR a8 ACCESSaHS IN ADVQANCE FOR OALL M QU CHMENT RED PERMITS <br /> CALL THE UNIT IV IN <br /> that I have prepared this application and that the work will be done in all <br /> with SanJoaquin <br /> I hereby certify applicable California State Laws. <br /> �✓�c� <br /> County Ordinances, Ryles and Regulations, and all a p Tifie/Company `d`P_ <br /> Signed Date <br /> Prinfl <br /> Print Name DEPARTMENT USE ONLY p <br /> 1. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 5' <br /> WORK PLAN DATED: t 7A O Ar <br /> Date Issued ?� b Date <br /> Appliptlon Accepted By Date a Final Inspection y <br /> Grout Inspection By Date <br /> Destruction Inspection ey <br /> COMMENTS I CONDITIONS: <br /> AID# INVOICE <br /> ACCOUNTING ONLY: RECD BY DATE PERMIT/SERVICE REQUEST# <br /> PE CODES FEE INFO AMOUNT REMITTED CHE`# ( Z. f i 0 2_) (0 ^ g/27/C <br /> 3 SO l ' <br /> IWC Letter of Authorization to sign permit_.Encroachment doc_ <br /> C-57_ =WAIVER_ <br />