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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <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 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 Hellth Division. <br /> AssesN4S <br /> WELL Location Z 15 W Mc,,n P.�Pc� CACross Street Lo c.uSfi City R'�Poe) .—Zip 953(,,(" Parcel# <br /> Sr Address Z 1 S W l�I� S-t City non zip q 53�Phone# ?6`J���1`�-3�SG <br /> PROPERTY Owner�avI Jo.,A�4 K etn V'%-Il" <br /> C-57 ContractorrA E:!j Address '?,91 Sherds 111% c City ST.�s Zip9sZsuic#L838Gs Phone#Zo9�j72-3570 <br /> Consultant Sub Contractor ATC- �SSoC Address 1117 L0,49. .&O 4- City cs Lic# Phone#2L9579-ZZZj <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BEP RFORMED: DESTRUCTION(choose type beIV) <br /> �fVEW WELL BORING(CPT,G PROB YDROPUNCH,,B i 3AUGER,OTHER-) OVER-BORE <br /> SOIL BORING# SB 7 PRESSURE GROUT <br /> WELL# <br /> 'Other. Grout Specifications: G:-nom-(' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M A- <br /> I]MONITORING a HOLLOW STEM DIA.OF BOREHOLE �Zu MULTIPLE CASINGS?Q YES []NO WELL CASING DIA: <br /> H EXTRACTION aAIR HAMMER/DRIVEN CASING THICKNESS N R TYPE OF CASING: []STEEL []PVC []OTHER:_ <br /> []VAPOR aMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS Q HOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> $'SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: <br /> aOTHER: []OTHER APPROX.BORING DEPTH Z S� 100—[]BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AJA _(if YES,list specifications here): <br /> 'COMMENTS: �o bor i n S -f- Z <br /> I � <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 and Regulations, and all applicable California State Laws. <br /> Signed x �r�4-�M <br /> 'PF Title/Company BMT rngr�-- SSOL• �+ <br /> VV <br /> V Date_ 61 <br /> Print Name O��w- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE S: <br /> WORK PLAN DATED. s q 1 9(� <br /> Date Issued F 1 \ Area_.!— <br /> Application Accepted By Date___ <br /> Grout Inspection By Date��Z/46 Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVI`CJEREQUEST# INVOICE <br /> C-57 W(_-WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />