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-� <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 <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 /> n1 // � '' I ,� �f] ,1 / n Assessors <br /> WELL Location � �I 1S 30 W E ��L+ /' 1' � rr+ Cross Street ly r� 1r'}tn. I<� Ciry Zip riParcel# 0_7Li_ <br /> PROPERTY Owner )✓ S}re/ C Mar- 14 <br /> as Address Iggoo W r'fl� 4wL� 1 cCity�Zip9S.212 Phone# 09/ /_9 -/Oy/ <br /> C-57 ContractorW�C ',� agr,R117r �jr � a Address P .o . R0� 336 City rat Vl Zip �lysE Lic# 71oo79Phone# � o7 -37=`134r <br /> Consultant / Sub Contractor /1TG Al iaYgeS -Tnc Address //17 tonal KI, /t5 DG-Lic# Phone# � O�l ' � '7 <br /> GIS Coordinates: X , Y , Township 2 N Range ,/ Section <br /> - WORK TO BE PERFORMED : DESTRUCTION (choose type belV) <br /> , NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER') 0 OVER-BORE <br /> 0 SOIL BORING # <br /> Q}.W ELL # M L.1 7 D PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ( MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? o YES ja NO WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCI. . '10 TYPE OF CASING: 0 STEEL % PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL $ r TREMIE TYPE TO BE USED: X AUGERS {] HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes <br /> � t a <br /> p No (NOTE : MAXIMUM FREE-FAA�LL DEPTH IS 30 ') <br /> OSOIL BORING OHAND AUGER <br /> GROUT SPECIFICATIONS: AA C ,..naj 32 � <br /> 0 OTHER: ' OTHEF,� APPROX. BORING DEPTH O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /VG ( 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances , <br /> Rules and Regulattii�ons, and all applicable California State Laws . <br /> Signed x IAMMa� '" �- r- �- • Title/Company T - r ' r <br /> Print Name Date 3 �1G1v1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : l) V ' <br /> WORK PLAN DATED : 170 SOD Z D/ . <br /> y <br /> Date Issued 3 o - O � Area <br /> Application Accepted B � � �g <br /> Date Final Inspection By Date <br /> Grout Inspection By / <br /> Date <br /> Destruction Inspection By <br /> COMMENTS / CONDITIONS : <br />' ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC ' D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> O <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachmc n O <br />