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o w <br /> ¢ <br /> WELL PERMIT APPLICATION! I=trAM SITE <br /> o - - MITIGATION <br /> - � �� iLLJ U) A - _OAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> c'3 AUG394 E,OWeber, Third Floor, Stockton, CA., 95202 <br /> i-W <br /> >Cl- (209) 468-3449 <br /> w EWIRONMEIvr <br /> pFR���Tf(WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Sari Toagwn 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 /> I Assessor's/ <br /> WELL Location !�l( tif. Cross Street EWM t�T City�iY/ lr✓ Zip�Parcel# /4 3-IS-O-/9 <br /> RAA((G 5 sn/6rG <br /> PROPERTY Owner WaPtllcvSf. CCM,— A&LV Addresszlt �• �Pdlukb City <br /> Zip !bPhone# <br /> C-57 Contractor16t�Yl _ZiPqL _Lic 7 Phoned yT3 <br /> 3 <br /> Consultant/ <br /> Sub Contractorkbkml /jg"lddressj �� - Cibfj&,K AI Lic#&Z27 Phone# 2,0? T/06 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PJ } <br /> EW WELL CE CPT, PROB ,HYDROPYI�CH,HAND-AUGER,OTHER') (]DESTRUCTION(choose type below) <br /> RING# Lf[]OVER-BORE <br /> Il WELL# PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING I]HOLLOW STEM DIA.OF BOREHOLE of MULTIPLE CASINGS?[I YES %(NO WELL CASING DIA: <br /> a EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL []PVC o OTHER: <br /> a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL f-OW TREMIE TYPE TO BE USED: []AUGERS Id HOSE <br /> a AIR SPARGE *PUSH POINT GROUT SEAL PUMPED: )(Yes []No (NOTE: MAXI UM FREE-FALL DEPTIA IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: Q OTHER APPROX.BORING DEPT � D a BOL ED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? t> (if YES,list specifications here): <br /> 'COMMENTS: <br /> T <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 /> 1 hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin <br /> Count r i an le and Regulations, and all applicable California State Laws. <br /> Signed x Title/Compan �S �YINL <br /> Print Name Date Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ¢ <br /> Application Accepted By Date Issued 0 0� Area f' OT <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �i�6� - - a ��♦ �' ?IS R# 0 02rlD3'�- <br /> 9/27/00 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />