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WELLERMIT APPLICATION FARM SITE-,`. <br /> FILECORN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT L <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y <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 /> WELL Locational ry, Wil I,� Cross Street CIU L.)e< S4 City p Assessor's <br /> Lws qe ti 'Ph. Co. n Zip SZp Parcel#114--Z-16-1(Z) <br /> PROPERTYOwnner H. 1c Address�fk�\ ��T CitySa.v -oO� Z09Sg3 Phone#9Z5--8�tz-1�SS <br /> C-57 Contractor QOJ�Q-)�L4\VAt Address 3(Z-L CSme :�\2 City2`7—, ZA WZ Lic#-117STU Phone# (6-(01&1\(.5 <br /> Consultant/Sub Contractor (.b2 Addressy�01'[_tL,\1p� a #>I� City Ck,&,Ip Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 8 SOIL BORING# p DESTRUCTION(choose type below) <br /> rgggtr�L# U OVER-BORE <br /> 'Other: y" H PRESSURE GROUT <br /> COMMENTS: Grout Specifications: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> / 40NITORING LLOW STEM DIA.OF BOREHOLE `6" MULTIPLE CASINGS?0 YES WELL CASING DIA: Zr/ <br /> []EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS Sc..l-t 0 TYPE OF CASING: D STEELPVC p OTHER: <br /> VAPOR HMUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED. % UGERS E HOSE <br /> []AIR SPARGE p PUSH POINT GROUT SEAL PUMPED:>1es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> HSOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> ,\ gELXT Ceii�e,V& <br /> H OTHER:_0 OTHER APPROX.BORING DEPTH (n� IW BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?��� 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 Ord' and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company SX P.{{ <br /> Print Name I �j'� 1+� Date a\ jlgjb1 <br /> /D/EPARTMENT USE ONLY <br /> y <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �412 ///14&r4f L.V <br /> WORK PLAN DATED:_ 2V2-11 �/ <br /> Application Accepted By - Date Issued ��/�/ Area <br /> Grout Inspection By - 1"� /G���Final Inspection By Date <br /> Destruction Inspection By <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> veru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 60 � 7y / SR# <br /> C-57-k WC=WAIVER_ C-57 Letter of Authorization to Sign permit Encroachment doc_ 9/27/00 <br />