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:1,-22r2i7_100 11: 3 : 20946S3 '3 FIFTH FLOOR FADE 02, <br /> 1%./ 4/' _ <br /> 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 r;f <br /> NON-REFUNDABLE PERMIT EXPIRES S YEAR FROM DATE ISSUED <br /> Applicat;cn is hereby made tr.Sar,Joaquin County fcr a Pormitto Coonstmgr andtar install tine work described. T hi::app!iCauo,i is Tade in compliance with San <br /> :oaquin County Deva!opmrrt Tile.Chapter 9.1115.3 and the Standarc;s of San Jnaquir,Counter pc.Iic H,ea!th Services.Envirormewai Health Givision. <br /> / n5:+0L50r6 <br /> WELL Location /' c S Csnss Street �n —City Jr a C.Ra.Z'p.1�pr� Parcel# <br /> FROPERTY Towner U S Address a �Z C ty-�_trot, 2,434?honeJ� �S�C✓ ZOC7 <br /> C-57 canAa,.to-_(1_ ?�s, Ad/a-.,s�O.t3aX ,5 < c;t;{gti�Uss��iPlus",z' <br /> Consu!,antISub Contra etof G�L-IL - ddrpss—sd.8—nc— 9� ciIV Qhone111 S�7S fly <br /> GIS Coo,dinates:X� _��C SLSuX� Township —�an9e Section _., <br /> WORT TO SE PERFORMED <br /> lE .'rEc L I BORING(CPT Gr:,OPROoE,HYCFOPUNOH,HAND-AUGER,CITHER-) O DESTRUCTION(Choose type q, ' <br /> � iL 50R.NG#. PR <br /> l� E <br /> p PRESSSURESURS <br /> GROUT <br /> "Other:-- `- Grout Specifications: <br /> COh13vtElVTS; <br /> TYPE OF VWELLlNSTALLATION„�TYPE CONSTRUCT!C SPECIr-ICATIDNS <br /> 0 MCWTORING HOLLOW STEM DIA.OF BOREHOLE_ MULTIPLE CAS!NG3P 0 YES ONO WELLCASING D'A: <br /> EXTRAG7;0N g AIR:HAMMER/:)RIVEN CASING`THICKNESS TYPE OF CASING: 0 STEEL 0 P`JC 0 OTHER: <br /> 0 <br /> VAPOR 0 NiuI)F.0IARY DEPTH OF GROUT SEAL— TREMIE TYPE TO BE JSECI: 0 AUGERS CHOSE <br /> 0 AIR SPARGE q PUSH POINT GROUT SEAL PUMPED: p Yes ZI No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> G <br /> HAND AUCF-R :aROUT SPECIFICATION'S& — — -- <br /> 501E 3CRING ® •-- <br /> 0 OTHER: _-0 OTHER__ APPROX.BORING DEPTH 0 BOLTED TRAFFIC SOX or 0 STOVE PIPE <br /> /CONDUC-TOR CASING F/ROPOSEO? (if yES Inst specifications here): <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 donna in OCcordance with San Joaquin <br /> County Ord' u and Regulations, and all applicable California Stitt:Laws. <br /> SlgnQd x — —TittelC.orrmpan)' <br /> print NameyT�.0 =-�L� e'r�I�` <br /> DEPARTMENTI USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -- <br /> WORK PLAN DATED: ? <br /> 4 licaton Aoaepted BY Data Issued + " Area- —• <br /> PP --- -- <br /> :iwt InspeCtioh 9y_ Dasa I Z, O0—Final Inspection By_ Date <br /> �struc8on Inspeciler,8} Date <br /> ;QMMIENh'S f CONDITIONS:------ —-- — _ — <br /> ACCOUNTING ONLY: I AIDA <br /> -PE CODES FEE IINFO I AMOUNT REMITTED CHECK 0 RECT)BY j DATE PERMIT 1 SERVICE REQ EST Ti INVOICE <br /> C-57____ WCC WA2VER,__, C-57 Letter of Autho izatl n t sign p rmit_. . Cntroackment doc� r 9�27�Od <br />