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WELL PERMIT APPLICATION TION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DID FISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, St ckton, CA., 95202 i <br /> (209) 468-34 9 <br /> NON-REFUNDABLE PERMIT EXPIRES i EAR FROM DATE ISSUED <br /> unty for a permit to construct aridlor install the work described. This application is made in compliance with San <br /> Application is hereby made to San Joaquin Co <br /> Joaquin County Development Title,Chapter 9-9115.3 and-the Standards of San Joaquin County Public Health Services,Environmental Assessor's Dwi9sio�n. <br /> city n f a Zip Parcel# O w-Z30 <br /> WELL Location q t l_'. Cross Street l� i , <br /> PROPERTY Owner.� . Me u O S Address 70-7 <br /> E. City 4 Zip 1 �Phone>��.g�3-1��:� <br /> 5>�O�Lic#r�PhoneI - 06 <br /> C-57 ContractorVdyaYl 6& a­ adress <br /> `/G <br /> 7-,1606 <br /> L� PAd,dres � G" Uc# Phone��) <br /> Consultant/Sub Contracto <br /> Y Township i1�117 -F1 Section <br /> GIS Coordinates:X ftT 'k �!� <br /> WORK TO BE PERFORMED: 2�]QSTRUCTION(choose type below) <br /> EW WELL 1 BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') 1 6 lL)l 11 OVER-BORE <br /> ` OIL BORING#P]^ Q-11 J�� 0 PRESSURE GROUT <br /> []WELL# <br /> Grout pecificat 1 C <br /> 'Other. r_ 1 <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS <br /> CASING <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE }t MULTIPLE <br /> OF CASING []STEYES �ELNOD VCLL[]OTHER- <br /> 0 EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESSp <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL En '! TREMIE TYPE TO BE USED: D AUGERS <br /> D AIR SPARGE ffl�PUSH POINT GROUT SEAL PUMPED: D es X40 (NOTE: MAXIMUM FRE24/0n5E-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or D STOVE PIPE <br /> D pTHER: 0 OTHER APPROX.BORING DEPTH S D <br /> CONDUCTOR CASING PRO OSED?/LA- (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ON ENCROACHMENT <br /> ALL REQUIRED INS EC orals. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADV <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 alifornia State Laws. <br /> Q�,� Title/Cc mpany e <br /> Signed x�2[.U. -, _b <br /> date <br /> Print Name l� DEPARTMENT SE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: L> u II <br /> Date Issued �W�' � ` ,��ea�� <br /> Application Accepted By �" "" Date__. <br /> Grant Inspection By <br /> f Date '� Final Inspection By <br /> Destruction Inspection B Date <br /> COMMENTS I CONDITIONS: <br /> RCODES <br /> G ONLY: AID# <br /> FEE INFO AMOUNT REMITTED CHECK# REC' BY DAT PERMR!SERVICE REQU INVOICE <br /> 100 <br /> 0 - q <br /> C-57 WC -WATVI=R G57 Letter of Autl�ori do to si p rmit Encroachment dac g�27�Q0 <br />