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WELL PERMIT APPLICATION FORM SITE0 <br /> MITIGATION <br /> � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> DEC 2 4 Z081 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) „ <br /> ENVIRONMENT HEALTH304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (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 /> Assessor's <br /> WELL Location I � Cross Street ��""'[ �5 City I - _Zip Parcel#! <br /> U� ?i} l+J. �Ar` Ci r� Z9p�53��Phone# <br /> Jw Address <br /> City <br /> a40� 12 <br /> PROPERTY Owner� �� <br /> Zein ^*f- Address 3E4 SI�.�r;`S �a� nl�!S I, n-uc# Pnone# Z-;s�4 <br /> C-57 Contractor Gity '�Z�P� <br /> Consultant/Sub Contractor <br /> 7 rt Lyrn . Address [,,o {�CL(w. City /�(0&U3 Lic# Phone#f Ste' <br /> Y Township Range Sectio <br /> GIS Coordinates:X � <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type belcy�) <br /> ,YNEW WELL I BORING(CPT.GEOPROBE,HYDROPUN H,NAND-AUGER,OTHER") q 1]OVER-BORE <br /> 'SOIL BORING# 0 PRESSURE GROUT <br /> a WELL# .i <br /> `Other: Grout Specifications: <br /> COMMENTS: l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING g HOLLOW STEM DIA.OF BOREHOLE Z-� MULTIPLE CASINGS?Q YES �.fVO WELL CASING DIA- dirk <br /> TYPE OF CASING: ©STEEL Q PVC BOTHER:_. <br /> []EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS�IL �- � <br /> VAPOR 11 M ROTARY DEPTH OF GROUT SEAL L5 TREMIE TYPE TO BE USED: O AUGERS []HOSE <br /> U AIR SPARGE USH POINT GROUT SEAL PUMPED: []Yes �-bo(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') . <br /> OtL-BORING B HAND AUGER GROUT SPECIFICATIONS: O-M' J^ — <br /> OTH � a OTHER APPROX.BORING DEPTH IS BOLTED TRAFFIC BOX or', (]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> t i <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ru es and Regulations, and all applicable California Staatter Laws. <br /> b AIAw �Dv�_ Title/Company <br /> Signed x i <br /> D { Date <br /> Print Name <br /> i <br /> DEPARTMENT USE ONLY . <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Z Area <br /> Grout Inspection By Date �—�Final Inspection By <br /> Destruction Inspection By Date <br /> I <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIQ# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# #RECIDY DATE PERMI7I SERVICE REQUEST# INVOICE y o''--& <br /> Encroachrrtenfi doc'E 9/27/00 <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to sign permit <br /> I <br />