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Q�vt�u Q �i <br /> Y�exo' 8-d7 b/ <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> NUIG 2 1 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMrr 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 ,,/� Cross Street (tJ City � L-_ZiPySL 7 Parcel# ZStJ'OF��" VPROPERTY Owner�lerr� I rf'00(-e' Address i' c5 C City &ytj - Zip�J Phone#L-P'-•,&35-27 Sc <br /> C-57 Contractor (�0�'GttJ�1GtDrrll'IaWAddress �0XXO City_P, Zip!t67/Lic#7/t�7 Phone# <br /> /��,,�, r� ' i <br /> Consultant/Sub ContractoflTT?X C -Jl rO�h Address /eW a&C—&31Y714d City rGtit� G{ Lic# Phone# �(l SIS 0760 <br /> /O(c 2 <br /> GIS Coordinates:X Y Township his Range 5C= Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below} <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) OVER-BORE <br /> SOIL BORING# 0 PRESSURE GROUT <br /> Other) OV�rt.L� Grout Specifications: <br /> MENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (/ <br /> 0 MONITORING A-'HOLLOW STEM DIA.OF BOREHOLE_JQ�_MULTIPLE CASINGS?[]YES YNO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S& LID TYPE OF CASING: 0 STEEL `,(PVC OTHER: <br /> �GAPOR D MUD ROTARY DEPTH OF GROUT SEAL Z'3 TREMIE TYPE TO BE USED: ')3�AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> S �c <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: r)`��� t3Gn�Oru - >rL5 - <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH OC)' )a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A&?_(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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or 'nanc , Rules a d Regulations, and all applicable California State Laws. <br /> Signed x �I Title/Company t//I'C� " - <br /> Print Nam / � �-� / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Ll <br /> WORK PLAN DATED: 1 �, <br /> L1 Date Issued �% �OZ ( Area= �-- <br /> Application Accepted By o � <br /> Date o �V 1 Final Inspection By Dat <br /> Grout Inspection By e __1 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: A.1,0 I <br /> [ACCOUNTTINGNLY: AID#E CODEE INFO AMOUNT REMITTED CHECK# 00 Q REC'D BY DATE PERMfT/SERVICE REQUEST# INVOICE <br /> ti (Cl <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/0 <br />