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- -­ ---. I 1 . IJ LUJYVVJYJJ r in rL-uum I1A(3L I <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />-� F1 'L� (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 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 />WELL Location -,� 7U 1 I,1/, Cross Street T J City i s arcel# o —LLC --- <br />PROPERTY <br />J (� I` 0 -0 <br />�ia✓1 Zip 1 <br />2 13 X10 i eat 14, 11 (� ry , - p 5WO Phone# c! 6 ' 77 `1- a1 Io <br />PROPERTY Owner�S G -O (I�.Dt" Orcl�'#r\ Address S �G 17d CI �/[�) 2 zi / <br />C-57 Contractor'` :15[: t��z pr,I�:h�, Address S(13) Uwtt_r L'Aje- City C4-7 �✓ y Z��6 jp IS� Lic1� %S (� Phone#�,� <br />Consultant I Sub ContractorEny,i nric16I Rix fv.4 54ddress� f ,5+ (X.� City VO ) SLIc# 1k1I.X3 Phone` <br />GIS Coordinates: X_ Township Range 6 Section <br />WORK 70 BE PERFORMED: <br />KNEW VVELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') Q OESTRUCTION (choose type below) <br />0 SOIL BORINr+ 9 0 OVER -BORE <br />0 PRESSURE GROUT <br />'ether: GROUT SPECIFICATION <br />COMMENTS: <br />TYPE OF WELIL <br />INSTALLATION TYPE <br />[I MON17ORlNG <br />)q HOLLOW STEM <br />0 EXTRACTION <br />p AIR HAMMERIORIVEN <br />0 VAPOR <br />[I MUD ROTARY <br />XAIR SPARGE <br />0 PUSH POINT <br />[I SOIL BORING <br />❑ HAND AUGER <br />p OTHER:___[] <br />OTHER <br />COMMENTS I f, AN r- <br />�5 N1- <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? d YES *NO WELL CASING DIA: 1 <br />CASING THICKNESS r _, i TYPE OF CASING_ Q STEEL 9PVC BOTHER - <br />DEPTH <br />OTHER:DEPTH OF GROUT SEAL L' --Z0" TREMIE TYPE TO BE USED: RAUGERS pHOSE <br />GROUT SEAL PUMPED: Yes Q No j(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATION I�U���N,ndl 1: ,T� <br />APPROX. BORING DEPTH_ M a X BOLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Vrr (if YES, list specifications here): <br />�5 <br />NOTE:_ OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS ✓ <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, State Laws, and Rules and Regulations of the San Joaquin County. <br />* CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x ' �l7 V�FtYAAA Title/Company ; 5 Bei �, Z ,'or.,, s I / / , I i l- h Yti e.1tu �GSII �; •r,i �au <br />Print Name UY1 SCI V i Date Iw i <br />SITE MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED �r1f `�Yiaa✓�.c�t ..2,. S+r cICf, <br />Application Accepted <br />Grout Inspection Sy_ <br />Final Inspection By <br />Destruction Inspection By Date " <br />COMMENTS / CONDITIONS: <br />to <br />ACCOUNTING ONLY: <br />AID# FAC,# <br />71 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D 13Y <br />DATE <br />PERMIT/ SERVICE REQUEST INVOICE <br />C-57 WC/WAIVER C-57 Letter of Authorization to sign permit Encr c 7/17/00 <br />SCo�2b �� <br />