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WELL tjERMIT APPLICATION FURM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES %IT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 2#0 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 SAjy 9: <br /> (209) 468-3449 <br /> t <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Tfl�fF,l�pNr �'�T 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 compSan <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. r <br /> Assessor's <br /> WELL Location 1-�3Z3 $• 1/g, ,411 Cross Street E. t'Ikw Rd City L Sc-,1!a L 21p SS37i Parcel# <br /> PROPERTY Owner gZo�,ev"� M." IgS Address 14324 S %-f�I� hCity ESc,t/w. Zip Phone# S�Zi6� <br /> C-57 Contractort'isc(" Yevivow�,c aI Address I" S�✓is �Iv� CityV6,IleytOnn��ipgSZSZ Lic#h3(«S Phone#�•1�2-3976 <br /> Consultant/Sub Contractor ATG k5i c ZA-1 Address 1114% lk-C Citye e Lic# Phone#24 S3S-?221 <br /> GIS Coordinates:X Y Township 15 Range R B Section 35 <br /> WORK TO BE PERFORMED: , <br /> )KNEW WELL/BORING(CPT, EOPROB YDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type beIV) <br /> S BORING# 58:1 t SR 2y Sii 3 Q OVER-BORE <br /> WELL# PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING o HOLLOW STEM DIA.OF BOREHOLE 2"• MULTIPLE CASINGS?a YES )(NO . WELL CASING DIA:/VA <br /> o EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ti,4 TYPE OF CASING: o STEEL []PVC o OTHER: WA <br /> 0 VAPOR G MUD ROTARY DEPTH OF GROUT SEAL 0,' 10`040' TREMIE TYPE TO BE USED: GAUGERS Q HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Ne4 <br /> a OTHER: []OTHER APPROX.BORING DEPTH le. 101,4J 0 BOLTED TRAFFIC PDX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?Ayv (if YES,'list specifications here): <br /> 'COMMENTS: Cir-P►-Lc a -N-jo Jo tO one 4b '50 <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. /.75>/I�NSigned xTitle/Company S-',1 I qeo'j'is'l11ATc b G16:�r <br /> � � Date Fal, ll 2UnS <br /> Print Name J„,. 1^jeP t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z 3 VQf i A A) Le C <br /> WORK PLAN DATED: -,di � I 0 5 <br /> Z( <br /> Application Accepted By Date Issued 2-11 Area � <br /> Grout Inspection By Date Final Inspection By Date____ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> g -n o `j `� L� 2 rs�o`;— SIR# q12-3(, <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />