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WELL PERMIT APPLICATION FOR <br /> F&TEA <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> �,� H n ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> o c� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 503 (209) 468-3449 <br /> -NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> a 6 V <br /> TE <br /> & iAW <br /> / '703 /N&ZG 'Wm4 ,Q.- `0 � /D'/� <br /> Assessor's <br /> WELL Location OT / r ry Crass StreeW3 u/•/J/�L)Jiry JTorKro.✓ •Zip Parch# <br /> PROPERTY Owner C,r{ .c rr.e 7' .-i Addressysf-6� 1"&PZPtV.06 Ciry r74M7cr� Zip 9520E Phone#ZO). 972. 6L Y? <br /> C-57 Contractor Address /.O,,Qoy t?6 CityZip 7i'Lic#/7}G9) Phone#I!� • 5'f2, 3L 7L <br /> Consultant/Sub Contractor&f Z 16vxn.P An,LkE AddresslfW QA-,e4,f7. /L ��iry ✓ittp.ic#� Phone#%/6. 86.�5�/ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> ,. U SOIL BORING#_ p OVER-BORE <br /> 19NELL# �+,.,- 2lr9 a PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> j?4v10NITORING O HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS-�'ES g NO WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS rCh/'/6 TYPE OF CASING: g STEEL-VPVC E OTHER: <br /> 0 VAPOR Y' <br /> n`MUD ROTARY DEPTH OF GROUT SEAL �/Zn' TREMIE TYPE TO BE USED: p AUGERS -*HOSEi�iPE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED:- es ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING UHAND AUGER GROUT SPECIFICATIONS. cchµY�Uf�Ztwrzz< <br /> p OTHER: fI OTHER APPROX.BORING DEPTH /Y'o ,g<SOLTED TRAFFIC BOX or p STOVE PIPE <br /> N/�O/ �i M 15 CONDUCTOR CASING PROPOSP E S (i(YES,lis pecifications here): /D N IYEE C- <br /> 'COMMENTS: r /��Y/I VY (i/JK-il, f/!" /LtI� ci ica ons he 4_ <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 done in accordance with San Joaquin County Ordinances, <br /> Rules and Regulations,and allapplicableCalifornia State Laws. <br /> Signed x C.� // > Title/Company Jrt_ rRdiFy fYbD/LdGf°t�/✓S7 <br /> Print Name_T4" l/• FaJ ' Date__i <br /> /- f �Il <br /> DEPARTMENT USE <br /> ONLY <br /> SITE MAP IN UNIT IV FILE,yo DRESS: fj CG! d' K a - ewala 0,8 -464.-q-I ✓ <br /> WORK PLAN DATED:_�7`—Z <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection — Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ZQD l 'nsu/ - 3395 6 �/ SR# <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />