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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 <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 <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 O `5 c c <br /> WELL Location Z� 6• 10A P_j< S7. Cross Street�AJ3 +Aa4x)Sr City S'IQ4CXroA.) Zip 520 Parcel# / _! <br /> PROPERTY Owner AZ.)24--o 6Ajur6PA Address/536 A). &Aj rcle S-7' Cityn-f:? TonJ Zip 95202_Phone#I!Zo9)"9I4X <br /> C-57 Contractor FLL44ZO CAGoSgkW_eS�/�Address jDC013eo pwg .5;rj q40 City011KLhxjb Zip 9`1607 Lic#7420/3 Phone#CSIO)Zb7-i/'1Zg <br /> Consultant/Sub ContractorT4cd�1�Address/E8 FjbWgW6cr G.ey4.k Phoneq�ojl)�14-oSla <br /> SUITi.t <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING PT EOPROB YDROPUNCH HAND-AUGER,OTHER') S 51 T6 S 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> `Other: _Grout Specifications:TPE-r/ZGAAAdtAtT, tzkAouro.0/T6 <br /> COMMENTS: S CpT Borzuue -7b t:�o ' )yy r��.v aSpZjAy,< TD jib ; /G�n►'gzRF <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 'I MULTIPLE CASINGS? 0 YES KNO WELL CASING DIA:_P� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC []OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SErLTO S42FAe g TREN11E TYPE TO BE USED: X S 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: VYes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: AlAAT C&nn1-_A!F_ <br /> OTHER: ce�Z 0 OTHER APPROX.BORING DEPTH—/-SO / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?-A/& (if YES,list specifications here): <br /> *COMMENTS:'-7--r&W 07 S 'QPT —Y3L4A&/IU6!S !� L'IS�� � e'.gpLL6G'T LtL."11A1'E <br /> S�L�SFl�t� C� T1+6 S CST SlT1✓S '�}� I So/L[ .mac / F T-n r-- GPT SITE S <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 <br /> County Orces, Rules and egulations, and all applicable California State Laws. <br /> dina <br /> Signed x Title/Company �' eF- 1�� <br /> Print Name A S E.� P F Date 0310/� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 2100 <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection Date <br /> COMMENTS/COND IONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D RY DATE PERMrr/SERVICE REQUEST# INVOICE <br /> �50SQ. co <br /> r-F7 \A//• -\A/4T\/FD r_;;7 I ottpr of Allthnri"tin to Linn nermlt Fncraachrt\ent doc 9/27/00 <br />