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20'39dd ££b£89b6o7 90M <br /> E, CDP Y <br /> WELL PERMIT APPLICATION FORM SITE y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> amp ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> N6 t11 (209) 468-3449 �DUx/TY �� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is reby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County evelopment Title.Chanter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> C a,-,,/ (yvr S�-aclrkx� 9s —pAssessgrs <br /> WELL Location—"N76� !lG'V rJ';—r Cross Street City Zip arcel# F'tq t hl )1 �� <br /> PROPERTY Owner (Ou,Vl� �cSLQ )_OQ Address City q(� r Zip __ PQhoone# <br /> C57 Contractor 4(eA :�K f— SA`111(•Afdd'ress � 0 �.rL Rd Ci Zip 1 f(0aLic#(�11 6y PhZe#� d� <br /> Consultant/Sub Contractor 1.F9. ��A n\ e- Addrest�09I " ' I I 'QI� +�Lic# N >� Phone# 2- <br /> GIS <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> $NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) I7 DESTRUCTION(choose type below) <br /> o SOIL BORING# a OVER-BORE <br /> R'W ELL#_SW� 1 I]PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?a YES AND SWELL CASING DIA:_ <br /> EXTRACTION DAIR HAMMER/DRIVEN CASING THICKNESS (V 40 TYPEOFCASING: OSTEEL ePVC []OTHER: <br /> g VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 6 r TREMIETYPE TO BE USED: GAUGERS 'WOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: `p)Yes �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING a HAND AUGER GROUT SPECIFICATION r <br /> a OTHER: ❑OTHER APPROX.BORING DEPTH��BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N •(if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 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 /> ",CALL THE UNIT <br /> �/IIV7�INSPECTOR 48 WORKING HOURS INADVANCEFOR ALL REQUIRED INSPECTIONS <br /> Signedx � 1m p �J�.(� Tlfle/Company -ir Q , -e-Y <br /> Print Name int Lh1�j�r2-�� �.n`' Date ti a 0 <br /> SITE MAP IN UNIT IV FILE ADDRESS/WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By yD�a�te ISSSSue Area <br /> Grout Inspection By h Date 1/�3�(i"t) /FSda Icti By > <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> ;-,?(Dl --- 32-4, i av- I ClOff DU o <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/12/00 <br /> Za 39Vd mnn1­1 HIATa cOncnoh 7 11 '�T non7ioTirn <br />