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i WELL PERMIT APPLICATION FOF ivl SITE <br /> ��- <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 0� � 0 ZJOi UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> t, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,pplication 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 /> aaquin County Development Title,Chapter 9-1115.3 and the Standards df San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> W ' <br /> WELL Location 1� 'Z G l�`� n Z(n Cross Streets vOc 2.,2,j V'ZA City Zip 9!C2 I Parcel#0? (j I X10 -04 <br /> ROPERTY Owner (L\�& Co ka Address �1 ?2 S E .`�t 1,,,./�CitY - O jkS, Zipq T?I. Phone# 1 Q7�i-�p�7 <br /> C-57 Contractor/��r C Address nU 3-7 '5�(,�u \-r� City ,Zip 5����Lic#r,�(Ja?Phone# u�- (()(�(, <br /> onsuttant/Sub Contractor G nV l r p(8 l� Address CityLic# Phone# <br /> GIS Coordinates:X 'y Township Range Section <br /> /ORK TO BE PERFORMED: <br /> ,_'NEW WELL/BORING(CP EO E,HYDRSPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> -&SOIL BORING# -t C�-Z rP�3 (l OVER-BORE <br /> G WELL# PRESSURE GROUT 0 <br /> Dther: Grout Specifications: N <br /> ;OMMENTS: Vl <br /> -YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS J <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z" MULTIPLE CASINGS?[]YES--kNO WELL CASING DIA: <br /> EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS /U- TYPE,,{OF CASING: IJ STEEL IJ PVC H OTHER: l �`I <br /> n VAPOR MUD ROTARY DEPTH OF GROUT SEAL :Z'�, I r41 REMIE TYPE TO BE USED: n AUGERS d HOSE <br /> AIR SPARGE IRPUSH POINT GROUT SEAL PUMPED: a Yes kNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> }(SOIL BORING G HAND AUGER GROUT SPECIFICATIONS: <br /> n OTHER: 0 OTHER APPROX.BORING DEPTH L O ! Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?-Pr)�_(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 /> hereby certify that I h ve prepared this application and that the work will be done in accordance with San Joaquin <br /> ;ounty Ordia es u es and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company l0 f <br /> rint Name <br /> J Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: c / <br /> pplication Accepted By ` 0 Date Issued `�� Area <br /> grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection By ate <br /> OMMENTS/CONDITIONS:. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> (0 00 0 7-�'G'-'j4u <br /> -57 WC -WAIVER C-57 Letter of Autho Iz io o An permit Encroachment doc_ 9/27/00 <br /> x <br />