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WELL PERMIT APPLICATION FO M SITE <br /> MITIGATION <br /> SAN JOAQUIN. COUNTY PUBLIC HEALTH SERVICES UNIT MIT1GAA <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <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 Health Division. <br /> N4S rr rl54ttev Assessor's <br /> WELL Location ZISW mo-kA �Jtiee+ Cross Street Locust CityR,Pgn Zip 95366 Parcel# <br /> PROPERTY Owner 7o.N, 10&A Address ZI S W. rA4,'A 5t City J�Qn zip 95364 Phone# 599 <br /> Valt.y <br /> C-57Contractor FiSc�n l:f1JjP•o�nyrityt}dAddress 'YR%� VrS P10.cA- City So�r �Ts__Zip9��Lic#6$38GSPhone# Zoe '1'1Z-3570 <br /> Consultant/Sub Contractor. A'T c- ASSoc-li1c. Address 111? Loner Qa.l hn*R CityM polos tb Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: (choose type bel <br /> ` NEW WELL PT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION Q OVER-BORE V) <br /> SOIL BORING# 1 <br /> Q WELL# - Q PRESSURE GROUT <br /> 'Other Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE L Z° MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA: N 14 <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS N A- TYPE OF CASING: Q STEEL Q PVC Q OTHER: N 1} <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XS-OIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER:_O OTHER APPROX.BORING DEPTH /00 Q BOLTED TRAFFIC BOX or Q 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.bedone in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California/Spate Laws. <br /> Signed x (^ N�nr^� _7 tie/Company ITEC- /tS50U0.1,GS LhC <br /> -� VC1/�YV-- 0VV1 Date_ /TIMI <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESfS: <br /> WORK PLAN DATED: l_l <br /> Application Accepted By ! !t��t��final <br /> ate Issued AreaGroutlnspection By Inspection By Date___. <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> I' <br /> i <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 37-7 <br /> 9127/00 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />