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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN .1C)AQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> [00Z L 0 '`C ' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) . <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 488-3449 <br /> NON-REFUNDABLE PERMIT t`XPIRES 1 YD E ISSUED <br /> ` 1ppliration is he made to San Joaquin County for a permit to constmot andlor install the work described. This application is made In compliance with San <br /> ioaquin County oavalopment Title.Chapter 5.1115.3 and th8 Standards of San Joaquin County Public Health 5erwices,EnVironmenAssses of gDivision. <br /> Cross Street CN�¢Zn w City .57'�c+C7o'ii ziP gS2ou" Parcel# <br /> 'WELL Location '8 <br /> )ROpERTY Owner<&T.¢M1Lx Address E NVQ w City <br /> 7DN- Zip 9S�e►.�Phone# ZG 9�8� }j <br /> 67 Contractor d-W �4�J*iG Address <br /> . 99. �o�c 416. Clty=&r�2ipEV t Lic#-L Sol/Phone# ?'16 7T ylco <br /> ' I� Lic# Phone# <br /> ti <br /> :onsuttant/Sub Contractor City <br /> Address !{ <br /> y ,Township Range Section <br /> ;RS Coordinates:X ;I <br /> iVORK TO BE PERFORMED: 'DESTRUCTION(choose type below) <br /> NEW WELL 10ORINIS(CPT.GEOPROt3E,I tirDROPUNCH.HAND-AUGER.OTHER-) t'JVER-BORE <br /> Q SOIL BORING# PRESSURE GROUT <br /> p WEU.ti W <br /> Grout Spedfica6ons- if, <br /> *Other <br /> OMMEN75: REliCcfTlR tcA- <br /> rYPE OF WELL IN TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGIOLLOWSTEM DLA.OFBOREHOLEMULTIPLECASINGS?i3 YES �NO WELL CASINGDIA_��� <br /> ]EXTRACTION 0 AIR IiAMMERNRIVEN CASING THICKNESS-VGµ o TYPE OF CASING' STEEL PVC I]OTHER--- <br /> ] <br /> PREMIE <br /> VAPOR U MUD ROTARY DEPTH OF GROUT SEAL ;}TYPE TO BE USED: Q ANGERS �Ii05E <br /> 3 <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED. $Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 34' <br /> I SOIL BORING a HAND AUGER GROUT ..SORI=tCATIONS:N �Lgva <br /> I OLTED TRAFFIC BOX or (1 STOVE PIPE <br /> OTHERt��R OTHER.- <br /> APPROX.BORING DEPTH /Op I <br /> CONDUCTOR CASING PROPOSED? 0,_.-,Of YES,list specifications here): <br /> Jr <br /> 'COMMENTS: IJ i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS- <br /> CALI.THE UNIT IV INSPECTOR 48 WaRKING 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 Sass Joaquin <br /> County Ordln s,Rules and Regulations,and all applicable California State Law' S. <br /> TidpiCompanyPflP�.Elr CEv �G+EocatJ _ <br /> Signed x <br /> Date <br /> Print Nam DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED 1 <br /> h <br /> Date Issuedl <br /> (� Area <br /> p Application Aot epted By <br /> Grout Inspection By <br /> Date Flea!Enspeotion By'• <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDMONS: <br /> ` ACCOUNTING ONLY: AID# <br /> i RtrC'D BY DATE Z?ERMrrI SERVICE REQUEST# INVOICE <br /> �. PE CODES FEE INFO AMOUNT REM TTED CHECK p <br /> 3so <br /> g cx7 G�� -2 4� 1115 <br /> I z ss o 2 <br /> ment doc 9/27f00 <br /> C-57— WC -WAVER C-57 Letter of AUthar'ization to Sign per'tnit Encroach <br /> , <br /> ;,r <br />