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_ • • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> w c� MITIGATION <br /> "1= o SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> _., N ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> -- - 6b- COS <br /> o_ 304 E. Weber, Third Floor, Stockton, CA., 9520 <br /> w (209) 468-3449 <br /> c) <br /> O NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED liratlon ism <br /> in compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work des This app Assessors p^„ <br /> Joaquin County Development Title,Chapter 119.3 and the Standards/o an Joaquin County Public Health Services,EnvironmentalParcel#, lD.iv�isis <br /> PPG (�J Cross SVee W (///J city <br /> WELL Location m Zip 20 Phone# 33- 96 <br /> �5too�lr q9d WIVA✓ P/— Gity_Ss '�� 2. 350 <br /> PROPERTY Owner �fI' _ /cry rn�d.,ra I/ L1c#68- 6SPhone# <br /> Zi 9S — <br /> /rJC7-f E.r/✓!� _dress 'z a�`r Ylr,c-G__CiIY slie P�- <br /> C-57 Contraclo� �_�._�irIAddressTf— Lic# Phone# <br /> Co <br /> Consultant/Sub Contractor a 0 E.LTL" Ranges Section <br /> Township_�— <br /> GIS Coordinates:X�'Y--�— <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> OVER-BORE <br /> NEW W ELL!BORING(CPT.GEOPROB NG#DROPUNCH.HAND-AUGER,OTHER ) 0 PRESSURE GROUT <br /> 0 WELL# Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLS CONSTRUCTION SPECIFICATI MUS TIPLE CASINGS?0 YES 0 NO WELL CASING DIA:__ <br /> 0 MONITORING O HOLLOW STEM DIA.OF BOREHOLE <br /> RIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC I]OTHER: <br /> 0 EXTRACTION D AIR HAMMERIDDEPTH OF GROUT SEAL <br /> 0 VAPOR 0 TREMIE TYPE TO BE USED: fl AUGERS OSE <br /> MUD <br /> PUSEAL PUMPED: O Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> 0 AIR SPARGE H POINT GROUT S <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: r <br /> � APPROX.BORING DEPTH YO BOLTED TRAFFIC BOX or D STOVE PIPE <br /> / OT ER� ti„,� 0 OTHER CONDUCTOR CASING PROPOSED. if YES,list specifications here): <br /> _.a carob <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 Ordinances, Rules and Regulations, and all applicable California StateLaws. <br /> o <br /> /( Gf / /I-,,�_/ ,3c� Ttle/Company t� <br /> Signed:! Jl L�s.rL V I Date <br /> Print Name 17c DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: —to-3 <br /> Date Issued / Area O <br /> Application Accepted By Final Inspection By ^'""""' -.77 Date_ -- <br /> Date <br /> Grout Inspection By Date <br /> Destruction Inspection By - <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> # RECD BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> -PE CODES FEE INFO AMOUNT REMITTED CHECK <br /> - 12- 352 <br /> 2� 9/z7/C <br /> C-57 WC�-WAIVER_. C-57 Letter of Authorization to sign permit_ Encroachment(0-4*1 g <br />