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WELL ERMIT APPLICATION FAM <br /> rV7 SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> bD--5C,1_ Tppr-y (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 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 /> WELLLocation_ -�' 5/ ,700 �./i1a;� „w /�f Assessor's <br /> t� T '/�- Crosls�Street � q City Zip Parcel# <br /> PROPERTY Owner.�',-TC- I-� Address PO L7C�C 1(<0 I S(g �-On p�_ q _ /�� <br /> p on City c. Zi 5019& Phone#dog- <br /> C-57 Contractor V I F)o R" Address 01110 V�dums Adv City s t,rpZipd14571 Lic#bS�ja Phone# s(O-,�o% -clf dl) <br /> Consultant/Sub Contractor l) S[-LP Address?3AS J 6f City h1Lkic# Phone#g//o-. <br /> GIS Coordinates:X ,Y e,Township Range Section <br /> WORK <br /> TO BE PERFORMED: - <br /> �WEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> / 'SOIL BORING#�$-I - S'� - 4 0 DESTRUCTION(choose type below) <br /> 0 WELL# <br /> 'Other: 0 PRESSURE GROUT <br /> GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE—_MULTIPLE CASINGS?0 YES kKo WELL CASING DIA:_ <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC <br /> []VAPOR D OTHER: <br /> []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS OHOSE <br /> �[]hAIR SPARGE )yPUSH POINT GROUT SEAL PUMPED: []Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> }SOIL BORING 0 HAND AUGER GROUT SPECIFICATION i <br /> U OTHER: 0 OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or <br /> 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): V <br /> COMMENTS: C W f <br /> NOT OFFSITE EIORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ` CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed 1 ( iW Title/Company <br /> Print Name 12-1Syt,- t 1 J2 , Date$ �- <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued / Arez _( <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 11� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> k <br /> X40/ 8,7— 1 19— L 002�7� 3 <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 7/17/00 <br />