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PLICATION FORM � SITE <br /> WELL PERMIT AP MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Fioor, Stockton, CA., 95202 d N Sfc <br /> (209) 468-3449 —� U <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 /> Assessors 7-�_Apo ?J C; <br /> Joaquin County Development Title.Chapter 31115.3 and the to <br /> of San Joaquin County Public Health Services,Environmental Health Division. <br /> C7 n �Cib SNoCk}on Zip s Parcel# <br /> WELL Location \S �rY Climb "� N uCross Street FranK\vl� I - <br /> LC <br /> S�Ck'IorZp y-5Ok Phone# y(eL-a71s <br /> PROPERTYOwner l�hn �C'rker • Address o�\SI Cwr,k r' I�� QI�YCiIy <br /> C-57 Contracto r Ire �,�`� Addressc/SD �la.�e �.dL cityMu-('inez zip y`/SS3 uc#GS6`!OI Phone# `1.25-313-SE b <br /> A�►I, nn *^e+r{clAddress 837 S1�aw \Zc� citySoak.{-,n Uc#_L,?dX� Phone# NL7-106L <br /> Consultant/Sub Conlraetor/-yrua c cit (�ec£nu•row <br /> X Y <br /> ,Township Range____Section <br /> GIS Coordinates: <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> '6YNEW W ELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HADD-AUGER,OTHER') a OVER-BORE <br /> r` ';SOIL BORING# PS - P[7 0 PRESSURE GROUT <br /> 17 WELL# Grout Specifications: <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING a HOLLOW STEM DIA.OF BOREHOLE aiN MULTIPLE CASINGS?11 YES 13 NO WELL CASING DIA:_ <br /> TYPE OF CASING: 1]STEEL 0 PVC I]OTHER: <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS C� <br /> VAPOR D MUD ROTARY DEPTH OF GROUT SEAL Il(]� TREMIE TYPE TO BE USED: I]AUGERS a HOSE <br /> I]AIR SPARGE PUSH POINT GROUT SEAL PUMPED: *Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING o HAND AUGER GROUT SPECIFICATIONS: rl) � <br /> 'S \G�nJt <br /> p OTHER:_[l OTHER APPROX.BORING DEPTH 'QFC BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> /I CONDUCTOR QgINGPROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: C(r\r S Ot6[ U4VtCPdL U+,I Tin,, GPI" 'TeCk n OI O <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 Ordin rices, Rules and Regulations, and all applicable California State Laws. ,(� <br /> Title/Company „r ra� -.SP 1,r� t-/hIX Geo tnw4v"11't <br /> Signed x_ p <br /> Print Name .hr�3+v J_Ler ^• (�1, IIer- Date 05--2Z-Of <br /> DEPAR�T`M'E-NT USE <br /> /ONLY <br /> Zoo <br /> SITE MAP IN UNIT IV FILE,ADDRESS: g "" <br /> WORK PLAN DATED: NO 7-7-X00 <br /> Date Issued CD .. Area <br /> Application AcceptedgpPficaU°n Accepted By��' Date <br /> Grout Inspection By Date Final inspection <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMONS: <br /> MPECODESFEEINFO <br /> AID# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_. 9/27/00 <br />