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WELL11ii-'ERMIT APPLICATION FC)*CM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> FILE COP Y <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 /> Assess <br /> +�` A St ') (,/>y City �'('erk �^ p Parcel#ofs <br /> WELL Location IPSO Suv r.,wa+. Crass Street Ct,sr�_ u Zi 9S2U1 <br /> PROPERTY OwnerW4 C�'w yr Address fosO Sn +'U�-.-..��/ City 5*+an'ati Zip4520l Phone# 09 7-6 <br /> C-57 Contractor IF(" Ewv�rpv,..,eti-I.,I Address -37q 51,eri"s -A c city Ay� Zip5252 LJc#6X3N6$ Phone#?W 772- 75.70 <br /> Consultant Sub Contractor ATC Rssoc. Address 1117 /c�?-J— �$ CityMGdesAo Lic# Phone#204 5+g-2u <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE P <br /> NEW WELL RING CPT, EOPRO HYDROPUNCH,HAND-AUGER,OTHER-) 1]DESTRUCTION(choose type belcW) <br /> 80RING# soil6ov,..c]c Oft Os�t (]OVER-BORE <br /> o ELL# O PRESSURE GROUT <br /> *Other: Grout Specifications: ller+ ce. 'f Qi,01 <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING a HOLLOW STEM DIA.OF BOREHOLE G 2" MULTIPLE CASINGS?o YES 0 NO WELL CASING DIA:.N1A <br /> o EXTRACTION I]AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: I]STEEL I]PVC O OTHER: W) <br /> p VAPOR O MUD ROTARY DEPTH OF GROUT SEAL Sj TREMIE TYPE TO BE USED: O AUGERS WHOSE <br /> a AIR SPARGE ) PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING )]HAND AUGER GROUT SPECIFICATIONS: Nd -k <br /> O OTHER: tl OTHER APPROX.BORING DEPTH `.�f.Jr O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NA (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 1 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. y I <br /> Signed x v X aM n'-4— �1�L Title/Company LI C- An snC t o. y -> Zac - <br /> Print Name J49:4\. ISI_ IAO Date III2-Q1OI <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: lt9 O (/lA <br /> WORK PLAN DATED: T� <br /> Application Accepted By Date Issued 111f,-'61,1 Area <br /> Grout Inspection By DateD ♦ ( Final Inspecficn By VA.w. Data <br /> Destruction Inspection By Date — <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 1� fjr9 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ 9/27/00 <br />