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y)R <br /> WELLERMIT APPLICATION RJRM SITE <br /> MITIGATION � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT-IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) i <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE COPY <br /> NON-REFUNDA13LE PERMIT EXPIRES 4 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 <br /> WELL Location 3`Irl�� 6l v u cross street W.1-sht(L,e city T }Zp3 Parce># <br /> r sstpiDl lit �c.Y City_: zip1S='71hone# <br /> 3 Pone# �_"I— Itch <br /> PROPERTY Owner rsern rola Leo Ad e0 0 `v-� caC-57 Contractor + 1Address CitLc <br /> Consultant/Sub ContractorAddress 30l 1[ � City �^c is#Phone#" <br /> GIS Coordinates:X Y ,Township Range Section . <br /> WORK TO BE PERFORMED: Y .. <br /> (]NEW WELL I BORING(CPT.GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER') []DESTRUCTION(choose type below) <br /> SO1L BORING# OVER-BORE <br /> []WELL# y []PRESSURE GROUT <br /> -Other- Grout Specifications- <br /> TS: � -y�e1 <br /> c e.rcrz <br /> Specifications- <br /> COMMENTS: S t ih ids! � <br /> b <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING (I HOLLOW STEM OIA-OF BOREHOLE �3i MULTIPLE CASINGS? YES PlO WELL.CASING OIA: 1� <br /> EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS N Ae TYPE OF CASING: []STEEL U PVC L]OTHER: <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL NPc TREMIE TYPE T0.13E USED: ykUGERS 0 HOSE . <br /> AIR SPARGE 11 PUSH POINT GROUT SEAL PUMPED:AZes [I No ((NOTA: MAXIMUM FREE-FALL,DEPTH IS 30') <br /> ROIL BORING 1]HAND AUGER l l,, GROUT SPECIFICATiON_S: £Ak — <br /> Q OTHER: '�OTHER_1Z\�Qt7t �ir�"1 APPROX,BORING DEPTH ��/ �BOLTED TRAFFIC BOX or �STOVE PIPE <br /> ——� <br />{ CONDUCTOR CASING PROPOSED? 0a0 (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 /> �h <br /> I hereby certify that I have prepared this application and that the work wil[ be done in accordance with:San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws.// r ° <br /> Signed x i TittelCompany k <br /> Print Name pct S\,\! Date 1D S p <br /> DEPARTMENT USE ONLY " .3 <br /> SITE MAP IN UNIT IV FILE, ADDRESS; <br /> WORK PLAN DATED: <br /> Application Accepted eyk Date Issued Area <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDrrHMS: G'�/ J' �✓ <br /> ACCOUNTING ONLY: AID# i FAC* <br /> PE COSIES FEE INFO AMOUNT REM rrED CHECK 9 RECD BY DATE PERMIT!SERVICE REDUES'f#. If"IVOICE <br /> r' 5~�v��7uJ 1Zt7aZ 2— <br /> C-57 WC -WAVER C-57 Le#ter of Authorization to sign permit Encroachment doc 9/27/00 <br /> E0 39Vd 800-13 H13IJ EEPE89VGOZ IE:El ;,0007_/V0/ZZ <br />