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• 0 ORIGINAL <br /> WELL,PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENiAh(5hMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 O 03 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> the work <br /> Application <br /> Development Joaquin <br /> C9-11oun1'S.3r and Assessor's Standards ds of San/Joaquinor )County Public rHealth TServihis ces,Environmental ronmenntal Healion is made in th compliance <br /> Division. San <br /> Assessor's 4 6jU-DI-2 <br /> br1 Say&-tA 1';e Ra Cross Street City RyVe f-aOAk ZipgS3G Parcel# Z <br /> WELL Location 23S S. <br /> PROPERL�YY (767 QF-pfrel S7 *1�ityScinFrnncSty Z;pw4(ui Phone#NtS)44U-2Uy1 <br /> Owner IJV r�.rro {}"Ii-J Dari Address 1, u[CG <br /> p o (jam 4 I6 City�sle Fon Zip`��4 uo# w Dy Phone# (q Ib 771~ <br /> C-57 Contractor\l a"w fir' 11' n4 Address X ]00 Ranoho � <br /> C erdevG <br /> Consultant/Sub Contractor S>=C��' �n`�rnn '`nul Address 3C1j K Iqcr2 P�\,Ste Ci h' Lic#61 OZ Phone#0110,G � (j <br /> GIS Coordinates:X ,Y <br /> ,Township 3Sou'Fh Range 1 Last Section�— <br /> WORK TO BE PERFORMED: []DESTRUCTION(choose type below) <br /> 'KAIEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) []OVER-BORE <br /> []SOIL BORING# []PRESSURE GROUT <br /> kfWELL#`I-7 Y-% V-9 U-IQ„� -tl J-t2t <br /> ' Grout Specifications: <br /> *Other: Well 165 <br /> COMMENTS: q-we(IS- 2-" d' <br /> � S-weds <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONMULTIPLE CASINGS?aYES �(NO WELL CASING DIA:_ <br /> []MONITORING HOLLOW STEM DIA.OF BOREHOLE)pv �i s s_w6S <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS scs 40 sclw SG E OF CASING: []STEEL <br /> PVC []OTHER: <br /> - kt9 s-wet <br /> 'VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL f ' TREMIE TYPE TO BE USED: AUGERS ,HOSE <br /> 1`c-,}R SPARGE []PUSH POINT GROUT SEAL PUMPED: gYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> []SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS:V wets _We <br /> []OTHER:—0 OTHER APPROX.BORING DEPTH 2n' —XBOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Nu (if YES,list specifications here): <br /> "COMMENTS: <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> �^ Title/Company <br /> Signed X <br /> QriGr Gare – Sj-a4 Geol ict Date <br /> Print Name DEPARTMENT USEONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z�SoL S <br /> WORK PLAN DATED: D dt? <br /> Date Issued As�p_Area )`- <br /> Application Accepted By i ice+/ Date 0 2- <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# ❑erw <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST It INVOICE <br /> 350 vl�/ -� SR# 3020 <br /> C-5 — WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/2' <br />