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C✓��C WELLPERMIT APPLICATION FORM SITE �V# <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 a Rug I rt <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 ith San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location UPP62 MA�bl CANA,- Cross Street T7tACY SL✓D, Ci Trr•wc 95376 Assessor's <br /> ty Y Zip Parcel# <br /> WEST Sine 5537$ 1209 <br /> PROPERTYOwner b,sreleT Address 13ZO 7-AcY a6YL, City TRACY Zip Phone# 8So3 <br /> wE516RN STMT. WEC-� C57 (41I,) <br /> C57 Contractor ZNc, Address P.D. eey, I L64 City SLc"t a_V Zip qg0j Lie#4f2F'18 Phone# 373-II I <br /> kc-raN M,CKEL6arJ 3D49, 15-re ZOO F, Dvk.wv Z,•, (9+6 <br /> Consultant/Sub Contractor ENyigolJ mc,TA� Address RS s N <br /> MkTA€W1 BavD. City 1,11L e# vs74v phone# 939-76- c0 <br /> 6.bT, Lo"G. <br /> GIS Coordinates:X S'7.7t0874.f ,Y- Tt. HZS844S- ,Township OZ $ Range oSE Section 23 <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> SWELL# RHI-( (,5 rSA N 9 6 N M E-T) PRESSURE GROUT <br /> 'Other. rout Specifications: �1 -SACr SAND 5e-,17 2 Y art IVCA7' C Ea r <br /> COMMENTS: P6MFan A'C 4• b onaVT SELEc—" AS. e✓6r2-r7 oae Ocacjo �✓FGAs�t3cc <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE l2 MULTIPLE CASINGS?[]YES XNO WELL CASING DIA: 8 / <br /> `EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL PVC 0 OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> []OTHER: I]OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: Adc ESS A&2EEMCNT N194IO 1.4-0b ,,,,/ W3316 11e Llh V-w-7-evz- '4. 7-y-zz.Z_ <br /> (jTTAcHEb) <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 /> Signed x P"(- ♦ Title/Company P12,76d7-r Nc-�72 �M� Tr- , <br /> Print Name /20r3LRT L, 11"A A1h 6.v7) Date 6-S--OZ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: TS V r", I�IL�c—�t CU R-W Q-C3 <br /> WORK PLAN DATED: 02 / p <br /> Application Accepted By Date Issued •�rea 06< <br /> Grout Inspection By Date d Y Final Inspection Grout Inspection By Date Final Inspection By�ate 7 y7 "0 — <br /> Destruction Inspection By Date' /_ q p <br /> COMMENTS/CONDITIONS: / <br /> ACCOUNTING ONLY: AID# FArfi <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2Ro2,, �o � S6 6-IZ 30!81 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc&J& 9/27/00 <br />