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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> JUL 1 0 2003 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT iEAL(H (209) 468-3449 <br /> PERPfiIT/SER iiCES <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 a9d the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ,y/o•Gp/ ?N S71J"+2� �e+- !b'!r"W/�/ '��Y Assessors Gri Y eY <br /> WELL Location p7AP4AV CEr/�2K/B�Cross Street CiGYA£A2 Ciry S-ZG/G7'4'y Zip 9 Z Parcel# o 5g-'- <br /> WELL <br /> PROPERTY Owner.c l'7-7 j,, S'7aZ /VAddress4V5- X/Cr d 5�17- ,CityZip l�}Zo2. Phone# G /lam/(J /•�O3 <br /> C-57 Contractor �IZIY ddress ���Z e5W10 -�/i12 Cites ✓1 Zip�Lic#7/��Phone#!l6 pif7'II,O`/ <br /> Consultant/Sub Contractor•�C /- Address ;a' �...L�e+IC � ty ic# Phone# &/ B,11-Of—lbp <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# E [J PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 'HOLLOW STEM DIA.OF BOREHOLE /t) MULTIPLE CASINGS?0 YES ONO W ELL CASING DIA: f� <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS---'41y410 TYPE OF CASING: H STEEL a PVC H OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1:5)-15- TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ,k-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER:_O OTHER APPROX.BORING DEPTH 1/0 OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: /i✓6L1.S 1,e- `en/S77L�fGT�O /f 6/ C/� %/LG G✓•�� ✓CCQ�Gt7� <br /> e,� a:' Ya 6e� 2 S . 7D Sctr Yo xe'f7V 1- (dile 4Ley /� Zj—o -'1-7-0 <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 ules nd Regulations, and all applicable California State��Laws. <br /> Signed X <br /> Title/Company ✓.�GfS7'� <br /> Print Name � ''"' ' Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ) ID <br /> WORK PLAN DATED: 7 <br /> Application Accepted By Date Issued_ Area <br /> Grout Inspection By Date <br /> L '✓�6f�✓� Date S' S C ' Final Inspection By )l1 Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cerx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 �a1 �'q.oD SS9sal q- z,1 03 sR# 3`f ill <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />