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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> Weber, Third Floor, Stockton, CA., 95202 <br /> 44 (209) 468-3449 FILE COPY <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 /> Assessor's /7 <br /> WELL Location 323 4 572 i" Cross Street /ofa....TG 5r City 5� zip 9S203 Parcel# /y 55-&:- <br /> i <br /> PROPERTY Owner LAt. Gr,•,co Address_7YOL tuoG C/si>>P City STr.E/on Zip 9Y207 Phone# (LD4) i4�-Y22S <br /> C-57Contractor Address ,1527 Fres.ro STr.eT City Fecno Zip 3711 1­ic#_fc4/- Phone#_(S54)26Y-7�Li <br /> i <br /> Consultant/Sub Contractor T L, b_. ,,_Address .2527 Fie>no5T. �i City ECj§„o Lic# Phone#_(SSY)208'-JOZ/ <br /> J <br /> GIS Coordinates:X ,Y ,Township ^)or Tl, Range G C.5 r Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, AND-AUGE OTHER`) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 2 1.4,,4-5- . µA-ivl 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DW- <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Ii SOIL BORING P HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH /o 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <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 Ordinance), Rules and Regulations, and all applicable California State <br /> Laws. d <br /> Signed x �[/ �p Title/Company / "�I/✓�iyli 44-0�S <br /> Print Name / /�'C-17 KAZ Y/JS Kr Date /I • `� '✓ �� <br /> DEPARTMENT USE ONLY <br /> r/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ — <br /> WORK PLAN DATED: 6a—//1 Z <br /> Application Accepted By Date Issued —r0O 1 Area M e/Q <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: r �( <br /> ACCOUNTING ONLY: AID# <br /> E;PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 290 I1 :S5 a 2$ QQ ZS / <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />