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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 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 Joaqui County Public Health Services, Environmental Health Division. <br /> r Assessor's <br /> WELL Locational��/ d� IW�+v Cross StreetY : HiA �e.,/ Zip 520 Parcel# <br /> —� ,I <br /> PROPERTY Owner. MP-,�w,o [.'A.Aj-A Address_/536 A). }�Nu'rS9_ ST' City SToclLronl Zip952,02 Phone# 9 7V-14X <br /> C-57 Contractor FU4Q0GGoSu*Axxs,1mrAddressLiXQBADWWASI!,,5;%4`4D City©/4*Xtb Zip"6401 Lic#7iQo/3 Phone#(510,)Zb7-gVZ8 <br /> Consultant/Sub Contractor(�&'yae�p &p_Tq 7&jj„ IAJL Address /ft Fg"jg W6cr GA"k Citys7' ,O.y Lic# Phone <br /> t�� 5(k <br /> �AT,9 r <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING PT EOPROB YDROPUNCH HAND-AUGER,OTHER-) S Y1 Tac 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�ZGtAAeAj : )3xAjrnytT6 <br /> COMMENTS:S GpT BoR,_e , -7b t�0'' 514,LV 4& tca �2i�Yt <br /> 71>156' /G6oilEoRF -M X115' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE " MULTIPLE:CASINGS? 0 YES KVO WELL CASING DIA:�_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS fill/A TYPE OF CASING: 0 STEEL []PVC Q OTHER: <br /> 0 VAPOR 0,MUD ROTARY DEPTH OF GROUT SEF,L'TD 5'4rjCAtG TREMIE TYPE TO BE USED: �F� 0,HOSE <br /> 0 AIR SPARGE XPUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS: V4-AT- C&ri tCilf T <br /> OTHER: C,PT _0 OTHER APPROX.BORING DEPTH / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 0 (if YES,list specifications here): <br /> 'COMMENTS:�Q VJLlAkmuGs l�) <br /> q t1 t TtF 6 5 C-AT S)TE S : 2 AjA / SOIL (-7/aP_./A_9!g!-, DIE E C_R T "31 1-6 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 Ordina ces, Rules and �egulati_ons, nd all applicable California State Laws. <br /> Signed x _ Title/Company SAFE <br /> Print Name �',e_ e,-- P F Date n310/10 4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �� Date Issued ,a Area p <br /> Grout Inspection By Date final Inspection By Date <br /> Destruction Inspection By 11 , <br /> COMMENTS/CONDITIONS: c—, L <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# C'D Y DATY PERMFf/SERVICE REQUEST# INVOICE <br /> 307- <br /> r_�,7 \Alr _\A/dT\/Fp .-Mit Fncroachment doc 9/27/00 <br />