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- WELL"yr ERMIT APPLICATION FORM SITE <br /> 11 5AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> v ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> pL ; •, { k Pik 1: 1 X04 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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/iiKMA/ W /j1/ C/ �ls Assessor's <br /> Cross Street City STrXd2/l!T/ Zip Parcel# <br /> PROPERTY Owner ddress yyS t//bw'?aY'1 City :5F7C/LID,�e Zip 'S> Phone# <br /> C-57 Contractor GV6liT Z/ - �L/ Address e�t City WZAk''lf Zip �YM Lic#. �7 Phone# f� 4Y 7Y76 <br /> Consultant/Sub Contractor�-�- -77KCfZOiYAress 30/7 /e%d-9104' i2 City 4,- rUL'0 Lic# Phone# <br /> GIS Coordinates:X ,Y—,Township Range�Section <br /> W RK TO BE PERFORMED- <br /> NEW NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRCIsyO ose type below) <br /> []SOIL BORING# ` OV -BORE <br /> WELL# P EGROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XIMONITORING XOLLOW STEM DIA.OF BOREHOLE -I-4L MULTIPLE CASINGS?[]YES )(NO WELL CASING DIA:_ <br /> EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS—ti'I YO TYPE OF CASING: flSTEEL ]j'PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: (Yes �77 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: /r 49",610T <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH , _}`BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N/D (if YES,list specifications here): <br /> `COMMENTS: 140u/`7ry414 G1JL�L$ MW�^l07 /t4W l� � An1Wt-Zyitli✓ ArL.9 ��7.!'-ofLT/�l� �✓� <br /> £zfJ 2. ryJN6 ro Hutu x/ = Z ° c✓LLc- 7-Z)= YO, s� 20-YO OMN-Z A61W-} =L"CA1464 Td - 77 SAW�y <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. F2-77 <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> "5cv-Z 61/cvE�L�TD=saw 5exa m 30-4v <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,,,Rules anq Regulations, and all applicable California State Laws. <br /> Signed x !/// n Title/Company S�Co e Z�7lr.�l//f 7e-. �� <br /> Print Name GL/i✓% /i5 <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: LiLwc- SV <br /> WORK PLAN DATED:=,�l l O i. <br /> Application Accepted By Date Issued 5 - P`olTLET� j a <br /> Grout Inspection By +-� Date 0 Z Final Inspection By C Date_ // S/0 <br /> Destruction Inspection By Date / <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> r=nr•u <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE <br /> 3 sc� I s"a 6 cZ GiQ 5 z4PERMIT <br /> 5 /SERVICE <br /> bSERoVICEt � T# INVOICE <br /> 66%(-)v <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />