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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT 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 peril 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. <br /> `�� ;� Assessor's <br /> WELL Location .3515 NAVY /SIVE Cross street City oC o Zip 203 Parcel# I(el O 02 <br /> f/a�EFF�j0ot-D,EliurvA 55(,+,hlicES <br /> PROPERTYOwner EQUILAN �ITERflti 5E5 IA-G Address'II060ZkF 38 rs Quc,� City KiRKLCUD.WA Zip&�3 Phone# j'(25244-2355 <br /> C 57 Conlractor62fyG VKlI6iH4 A-rESTiNG- Address,�5o HOWF Kfl/P Cky I EZ Zip 91553 Licri 85 65 Phona#k5) -WO <br /> Consultant I Sub Contractor laxicum 0.1,4gE966 /51Eµ5 Address It WFUToU QVEUot city OAN Caws Uc# Phone#boo)55I-ou <br /> GIS Coordinates:X .Y .Township Range Section <br /> WORK TO BE PERFORMED:_ <br /> )(NEW WELL I BORING(CPT.GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION(choose type below) <br /> U SOIL BORING# p OVER-BORE <br /> WELL# MAI-29 a/' a PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING HOLLOW STEM DIA.OF BOREHOLE �G „ MULTIPLE CASINGS?0 YES )(NO WELL CASING OIA:_-4-L <br /> i7 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS �-�440 TYPE OF CASING: 0 STEEL XPVC p OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ti 4 • TREMIE TYPE TO BE USED: O AUGERS HOSE <br /> p AIR SPARGE a PUSH POINT GROUT SEAL PUMPED:�qYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING J)HAND AUGER GROUT SPECIFICATION 95% CEueNT /5-/ 43a/`f-mf <br /> 0 OTHER: 17 OTHER APPROX.BORING DEPTH 30/ 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? [7_(if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,State Laws,and Rules and Regulations of the San Joaquin County. <br /> "�C�L�L�TH NIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x�/UW. L&11 F47- U,CE44 1,2 ulNg ThtelCompany �2a4EE rt.G1A/EER,�X(CFE(�l. MgMT 4y 76g5, Vc. <br /> Print Name_ a 9J .♦♦ILI Dale -40 <br /> SITE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued /t CD Areae-ZJQGjV <br /> Grout Inspection By Dale Final Inspection By Date <br /> Desuuclion Inspection ByDate <br /> COMMENTS/CONDITIONS: AAn I,P / QOMn &A!= <br /> ACCOUNTING ONLY: AID# �� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECID BY DATE PERMrr 1 SERVICE REQUEST# INVOICE <br /> Dirt- q7 /S tln !S IXhSR# <br /> C-57�— WC/WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc____ 7/17/00 <br /> Z0 39Vd 800'1d HiJI3 EEPE8906OZ 86:9T 000Z/8Z/80 <br />