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WELL PERMIT APPLICATION FORM SITE <br /> UU MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNIT IV <br /> WG 13 20p1 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> GrjEpj1 HENGIH (209) 468-3449 <br /> EN?R"AITISER`+IGFs <br /> pE � 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 /> // �-.� z�- Assessors <br /> WELL Location I'm wok, I f� S' �f cross 7Gtreeis_�Lv_[(�w�l .City Zip Assessors Asses 2-39�a ®-o% <br /> 1 ud/fat vno eG� (ma <br /> rt <br /> PROPERTY Owner6kf1e- &;C121n Address' City Cq.h Rdray„�'Zip� Phon g <br /> C37 Contracto - d- Address CiryZip�°fLirc�#re Phone#?< <br /> g - T .131 az <br /> Consultant I Sub Contracto ss !SD City Lic# Phoneaf�(a-X!i{�04/Oe <br /> Gdr` ik2 <br /> GIs Coordinates:X .Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,Hi'DROPUNCH,HAND-AUGER,OTHER') U DESTRUCTION(choose type below) <br /> V BORING# 4 P-f At id 6P-4 11 OVER-80RE <br /> U W ELL# U PRESSURE GROUT <br /> 'Other- Grout SDecifirations: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING U HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?L YES U NO WELL CASING DIA:tU,4 <br /> 0 EXTRACTION 13 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC U OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL- / TREMIE TYPE TO BE USED: U AUGERS WHOSE <br /> 0 AIR SPARGE ;IPUSH POINT GROUT SEAL PUMPED: flYes 1l No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: <br /> (]OTHER- 0 OTHER APPROX.BORING DEPTH !2121 U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 Ordinance , ules and Regulations, and all applicable California State Laws. <br /> LPrint ned Ti e Compan mNae �/j Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> gyp,Aid gy Date Issued Ld`" Area <br /> Grout Inspection Bya e Fnal Inspection B Date <br /> Destruction Inspection B15-7", Data <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMnTED CHECK# REC'D BY DA PERMIT/SERVICE REQUEST# INVOICE <br /> P_q 0 l 3 V. D0 KI;I I - <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho ation t s'gn mit_Encroachment d0-c_ 9/27/00 <br /> TE:£i 000Z/60/71 <br /> £0 39dd "13� Hl�I� ££4£894602 <br />