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Fll CQPY <br /> 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 CW <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 /> `' ,,, {A{,,,p Assessor's <br /> WELL Location 7-120 ���'lWoo4 r V Cross Street bran k ly�t A e City Sloc.,LLII Tp 9So2O'I panel# <br /> PROPERTY Owner ;'l'('y o� San �eneun Address CityZipone#_� <br /> C-57 ContractorviQ,q g 1 A S,-�(n-�u Address 9So 11w6 R Ciptykf 4,r&z Zipy" 3 Lic#1 fl '107 Phone#92S-313-5500 <br /> Consultant/Sub Comractor/td'v&� J)6eotinv,T Ilhe !Address 337 Sl,cw s2A City S'(cck{on Lic#�.W.4 -7 Phone9(17-J001f <br /> GIS Coordinates:X ,Y - ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(UP 1.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> VSOIL BORING# P9 0 OVER-BORE <br /> WELL#. 0 PRESSURE GROUT <br /> *OtherGrout SpedScations: <br /> COMMENTS: Pwrk Lc.ne, Mnr3rn of alaO FI wct /�vC <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA OF BOREHOLE Zt°r1 MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS—�—TYPE OF CASING: ]]STEEL 0PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL,,/ T rTREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE ,PUSH POINT GROUT SEAL PUMPED: D-res 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIo <br /> ONS: pot� l <br /> 0 OTHER: OTHER APPROX. BORING DEPTH eb 4 T- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,fist specifications here): <br /> 'COMMENTS: CPy" Bort w <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ori 9 ces, Rules and Regulations, and all applicable California State Laws. N <br /> Signed z pp Tde/Company Cnv Ta Ml�rl4/ S9ec' 4 34-/-A't,c.+ j G ro <br /> P nt Name <br /> rht" s+op�c IL k\' f- Date S'Z-2-O 1 <br /> �I � DEPARTMENT USE ONLY <br /> �_ _ <br /> 4Mp IN UNIT N FILE,ADDRESS: a�s a <br /> WORK PLAN DATED: D O <br /> Application Accepted By / Date Issued <br /> Grout Inspection By DateFinal inspection By Date <br /> __ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID#. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> XZ <br /> doc_ 9/27/00 <br /> C-57_ =WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroachment <br />