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WELL PERMIT APPLICATION FORM SITE <br /> SAN J0;4QUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> —ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 3D4[l�. Weber, Third Floor, Stockton, CA., 95202 FILE COPY <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's made in compliance vn 1 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Envirc ..mental Health Division. 1, <br /> Assessors <br /> WELL Location 3/0 5 5Pe r Cross Street /..a:Fa/cam Si- City S'1"oc�Tn Lp 95-.103 Parcel# jyy-Dye- <br /> PROPERTY Owner LLoL- Franco Address 71/OL City _<TocKT„ Zip 95207 Phone# C209) YG6-.v <br /> C-57Contractor ,,, LoloonJmla Address 2,527 /rnsro 5T/ecT Ciry Fcsno Zip 3711 Lic#50,./5-9 Phone# (5s9).Z0-7o Z/ <br /> Consultant/Sub Contractor Address 2x`27 Fi-sno 1!iecr Ciry Fres,,o Lic# Phone# (Ss-9)165-'-7071 <br /> GIS Coordinates:X ,Y ,Township l .1forn Range__4 Eos7- Section <br /> WORK TO BE PERFORMED: <br /> 1 EL W WEy/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) I DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# / C rMW-/] II PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II MONITORING I HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES I NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5--J,41c yo TYPE OF CASING: 0 STEEL t PVC 0 OTHER: <br /> - <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /JA TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: NA <br /> 0 OTHER:_ 0 OTHER APPROX.BORING DEPTH 26 r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifica5ons here): <br /> •COMMENTS: -, tie Ilett( '/ '/ (o SJler/ :.7A c,zoe.r T../iowit eo/lecrov, of <br /> < dle u <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 Rules <br /> �and <br /> QRegulations, and all applicable California State Laws. <br /> s. <br /> Signed x 7�//�� .I�f►'�^V�+ Title/Company /yw/A �/j4 ',/n ^" B`SS <br /> "7 <br /> Print Name ,A` -Z 7,4j'S K( Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '5V f�DdIC -S_ �iUc�t—GDP> <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued --� Area 6694- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: "CV /o gbf <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE ATE PERMIT/SERVICE REQUEST# INVOICE <br /> JflO ( g� � <br /> C-57_ WC=WAIVER_ C-57 Letter of Authoriza ion to sign permit_Encroachment doc_, 9/27/00 <br />