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WELL PERMIT APPLICATION FORMO SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTHStockton, CA.95202IVISION , <br /> 304 E.Weber, 7hi(Z 9 } 4°° 68.3449 <br /> NON-REFUNOAgLE PERMR EX <br /> PIRES 7 YEAR FR M D TE ISSUED <br /> Assessors c —I <br /> Chapter 9.1115.3 and 1119 Standards of San Joaquin County Pvbl{c Health Services.Envirgnme�r I1n Otvision. <br /> IppllraGen is hereby made In San Joaquin CoOnty <br /> for permit to w3tlUcl andlor install the work described. This application Is made in compliance w. <br /> loagdln County Dewlopment Title, R� Clb1 c��p zvQ <br /> HELL Location yG 7� En, '" '-� �T Cross Street o0�p � Ciry�`K �p�s�� ane# tib Z``�-7 <br /> TRH MC IP/iTZW <br /> Ttl Address �!-- 7 X 3 � VA Lt E^-I 7 <br /> PROPERTY Owner . - c#i^3''�'Pnone#2��' »O� J <br /> s37 J N ER t S Qt_, City S -I,v_< ip i aD <br /> IlglO ffcRITALC 19 �honefi5�l�-�56- <br /> asT contractor I s c.H E� J t . ares Bv�✓ Llg#�3 <br /> /_�H� I� Addresses 0 7-Fi Ciry�', ;5 <br /> Consultant l Sub Contractor Range L2� SeUlon`r� <br /> Gts Coordinates:X�—�' <br /> �,,1�_',TOwnshiPt—�— <br /> SLC HGp QDESTRUCTION(chVSR.Dtype below) <br /> N�t]_RKORE <br /> To BE PERFORMED: GEOPR00E.HYDROPUN CHHAND-AUGER.OTHER') 0 7, p� p PRESSURE GROUT <br /> `KNEWWELLIBDNNG(CPT SOILBORI.HYNG It M'T <br /> �` p III <br /> WELL# Grout Specifications: Iti Q <br /> Other: <br /> COMMENTS: �C r"yrcbct t 1 3 03 <br /> INSTALLATION TYPE CONSTRUGnON SPECIFIC0.TIONS s YES O NO WELL CASING DIA:_ <br /> TYPE OF WELL �� MULTIPLE CASINGS. O <br /> HOLLOW STEM <br /> CIA. DOREHOLE� TYPE OF CASING: ll STEEL o PVC a OTHER: <br /> 11 MONITORING 0 AUGERS CHOSE <br /> 1]EXTRACTION QAIR HAMMER/DRIVEN 0ASINGpTH F GROUT <br /> TREMIE TYPE TO BE USED: () <br /> p MUD ROTARY CPTH OF GROUT SEAL_ �� <br /> p VAPOR No NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> j(PUSH POINT GROUT SEAL PUMPED: D Yes <br /> D AIR SPARGE /' GROUT SPECIFICATIONS: CtM T i� <br /> HAND AUGER Q BOLTED TRAFFIC BOX or p STOVEPIPE <br /> )(SORBORING APPROX.BORING DEPTH <br /> r�OTHER:_ _n cTHER� CONDUCTOR CASING PROPOSE04 (If YES,list speeificel ons <br /> ,COMMENTS: <br /> RE ACCESS OR E <br /> NOTED OT NSNSPECORINGS TOR 48 WORKING HOURS'IN A VANC IFOR ALL REWIRED INSPECTIONS. <br /> CALL THE <br /> I hereby certify that I have prepared this application and that ablehCalifornia llState Laws.e done in accordance with San ff Joaquin <br /> Regulations,and all appGCCt_06,ST ve, .v Il: <br /> County Ordinanees,Rules. Reg Ttde/company SE A:1 c-R <br /> Signed% Date <br /> u�tz-r-� a� <br /> Print Name -/i CAC 10 NOIJ`>t <br /> pEPARTMEN7 USE ONLY <br /> —ion, z <br /> SITE MAP IN UNIT N FILE, ADDRESSu� L <br /> WORK PLAN DATED: 2, Area <br /> DatelMuad Date C, <br /> Appltratlon Accepted Ely—1.1 _pate I Final Insped5011 BY <br /> +ten � <br /> Grout Inspection By_.�>� Data <br /> OcsWcho ,Inspection By Z <br /> COMMENTS I CONDITIONS <br /> ACCOUNTIHG ONLY: AJD# PERMIT I SERVICE REQUEST 4 INVOICE I <br /> CHECK" REC'O BY DAT 2 I L, <br /> PE CODES FEE INFO AMOUNT RE��O ' 1-2, I'> 3 OC <br /> 3St71 `6 9/27 <br /> -57„ WCC WAIVER C-57 Letter of Authorization to sign permit,Encroachment riot_ <br />