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IREMEVVE D WELL PERMIT APPLICATION FORM <br /> JAN 3 0 ZO�Z SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES M�TiGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> PERMIT/SERVICES (209) 458-3449 - <br /> NON—REFUNDABLE PERIUrr PTIRES 1 YEAR FROM BATE ISSU%p <br /> (prication is hereby matte to San Joaquin County far a permit to censtrvct anWer install the work described. This aMffcahcn is made in=;Mptlance vYdh San <br /> JCaq=County Development i ille,Chapter 9-1115 3 and the Standards of San Joagum County Punfic Health Services,Ennvircnmental Health 01visran. <br /> Assesso <br /> F—L I..n=ion as S�fQ �� � --C-Mss Stmt Cay_S7'rb1L _ zlp�.P3iS 3-2-0-6? <br /> PRCPM:ny Owner Ce -Address;%* pat4to fg) -Crty84WD77<"n- Ag Phcne <br /> f "67 C.ontractnr !- �2e11f Add.,s E�0 /�7� /� C+tY� -Li��Plton 3�- 3 <br /> Consutiant I Sub Contracto �k!«nCy�a l Ad: �7 / SOFA c� %i k-5d � r Z? Fh ne# b <br /> Coordinates.x 'y .Township_ E ange Secdon <br /> WQR RERFORMED- <br /> W BORING(CPT GEOPf2OM HWROPUNCH.tiAND-ALIGER,OTHER-) 13 DESTRUCTION (choose type below) <br /> OIL BORING OVER-430RE <br /> I`LLA 4 PRESSURE GROL E <br /> Cer GrtautSpetafrcatroris _ - --___-- _ _ _ <br /> COMMENTS <br /> tym-OiF-WML INSTALLA ION TYPE CLONSTRI]gTIQN SPECItiCAMONS <br /> B MONITORING CLLOW STEM DIA OF BoREHcLE?#�muLTIPLE OASINGV KYES UNG WELL CASING <br /> CTION 1]AIR HAMMERIORIV•EN CASING THICKNESSS[-1.1_ -P-- TYPE OF CASING: 13 SI'E-:L Xoc 11 O'iH tr <br /> INEWR (I MUO ROTARY DEPTH OF GROUT SEAL E± TREMIE TYPE TO BE USED-"'XAUGERS 11 HOSE <br /> A1R SPARGE [I PUSH POINT GROUT SEAL PUMPED AYes 1]No (NOTE_ M UM FREE-FAL DEPTH IS 3L#°) <br /> 11 SOIL BGRING 1}HMD AUGER GROUT SPECIRCATI4NIS ��?T���_ (jWaZ - <br />'[I OTHER: TI OTHER _ _ _ _ APPROX.SORING DEPTH— / .3CLTW TRAF=310 BCX or a STOVE FES <br /> C OMOUCTOR CASING PROPOScD-' (if YES,list speafi,,d ns here) <br /> .COMMENTS, p4c gI t`c d <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 l have pre red this application and that the work will be doge ISS a=rdanre with San Joaquin <br /> F County don R u an <br /> egulations,anti ail applicable California State Laws, f /� <br /> Signed)i;_ 'l_. TclselCompany '�/srl' G fGc1 1 A' VAnt <br /> I f / <br /> pent Mama AU -U' (Irl Dale <br /> f DEPARTMENT USE ONLY T ^� <br /> SITE MAP IN UNIT IV FILE,ADDRESS-. <br /> WORK PLAN DATED'. —2, —O f <br /> Application Accepted lay Date Issued ..2 Area O <br /> GMW Inspectim By 02teFcnat Inspedian By Date <br /> Destruction Inspection By Date <br /> A&MAKEM I COAI17ii1ONS <br /> AGCOUhrnNG ONLY: AIO# <br /> PE C0IDeS FEE INFO AMOUIQT REt1111TTED CHECK Ig REWD BY DATE Psmm ae VICE REQUEST# MYOICZ <br /> C-571— WC WAIVIER C-57 Letter of Authorization to sign permit Encroa6lnerst ciao 9/27/00 <br />