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WELL PERMIT APPLICATION FORM SITE <br /> A) SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> <� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> fl (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 Tile,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,E—n�viirronnmmental Health Division. <br /> Assessors <br /> WELL Location Kv LuJ �L% -5 Cross Street .�� 9 � Cityt Z5' _Parcel#/37�d2c�—Q� <br /> PROPERTY Owner/LD77� A�ddr�esys��r�it/! -T Cit�i�el� ,eZ p��i Phone ��9 <br /> C-57 Contractor �it/F'� Add-drressf(Y.Y�/t' l�� CI Xj4 Zipjr4Llc#i��`^'�Phon &/�(4 <br /> Consultant/Sub Contractor �.�iYl-PLG � Address�2r 63�A7Z'0 City//ic# Phone#! � ��}YJ <br /> GIS Coordinates:X ,Y ,Township Range (O Section _ <br /> RK TO BE PERFORMED: <br /> IEW WELL/BORING(CPT GEOP ,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> BORING# D OVER-BORE <br /> 0 WELL# / {— -�PRESSURE GROU <br /> 'Other: Grout Specifications:I.�l r/' /c?S%S5­7D . y <br /> COMMENTS: u� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ��// <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE ` MULTIPLE CASINGS?0 YES [NO WELL CASING DIA41'T <br /> [EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [STEEL D PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DgPTH OF GROUT SEAL. ca�-T� TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes [No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> Iy�OIL BORING AND AUGER&OWGROUT SPECIFICATIONS: &e'� 6 <br /> {["OTHER: <br /> [OTHER APPROX.BORING DEPTH [BOLTED TRAFFIC BOX or [STOVE PIPE <br /> yC,ON9UCTOR CASING PROPOSED? A f4' (if YES,list specifications here): <br /> 'COMMENTS:_ �r^"•�e.S UO v/y <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 Rules and Regulations, and all applicable California/State Laws. <br /> Signed Title/Company <br /> Print Name �/LGE�j Date <br /> DEPARO�T��ME'�NN�T USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: i <br /> WORK PLAN DATED: 0 2— <br /> Application <br /> Application Accepted By Date Issued 3 Area ®� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACO <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 101 1 j <br /> Sg# joV .24!11 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />