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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.'Web&, Thjrlj:Fjgor, 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 andlor install the work described. This application is made in compliance with San <br /> Joaquin County Dave lopment title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> Nava- <br /> 11 ,_1 L� /) t� Assessor' <br /> WELL Location ��� /VQ ��1 Y� Cross Street ��tS'Fdj u2ity. Zlp%� 3 Parcei# b <br /> 11 E ��}iv^ I r1 I e �,yt S7S 'hC 4y)e Mwl�ttns <br /> PROPERTY Owner 0✓T �Pyw i yj S Addres� f`f a(� XIXJtiI'f tilyu cityZip •'hone 9-1� r7 3l 806SX <br /> C-57 Contractor Address BAX City f1 �ZpIVS71 Uc#, )0'70Phone4/6-777—qmo <br /> Consultant I Sub Contractors wtI,-, �t V Address il!"), CI 1e Lic# Phone#9a `/SO (587 <br /> GIS Coordinates:X Y Township Range Section <br /> YQRK TO BE PERFORMED:_ <br /> )(NEW WELL/.BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> X SOIL BORING# CBI 'h a -C Li G$I,;L� Q OVER-BORE <br /> 0 WELL# J Q PRESSURE GROUT <br /> "Other: Grout Spafications: <br /> COMMENTS: ^✓t 1­0 "— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE /I MULTIPLE CASINGS? Q YES NO WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS a' TYPE OF CASING: D STEEL D PVC D OTHER: <br /> Q VAPOR 0 MUD ROTARY DErri H OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS HOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: D Yes `Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUG2R GROUT SPECIFICATIONS: j'elw �Vkd �il IWMo,�t7,tcyj— M � V <br /> 0 OTHER: ` OTHER&0A G , APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ances ules and ReguI t* ns,(an�d, all applicable California State Laws. <br /> Signed x V l V� 1 TiQe[Oompany v `I <br /> Cj wit'- <br /> Print Name c)<nA e 1� 14 J ap _Date I b/ 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / <br /> Application Accepted By tet, ` Date Issuedlb 10o Area orl.V/���u3 <br /> Grout Inspection 6 kli., Datej/ O19 Final Inspection By Date <br /> Destruction Inspection ByDate LL <br /> COMMENTS/CONDrrIONS �CCc ( CZ� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMrT/SERVICE REQUEST# INVOICE <br /> 50! 8� t 3r� Ar- o civ rho qv <br /> C-57_ WC -WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> ('9 39dd dCO�d H1dId EEbE89b60Z Sb :DZ eae�ietiet <br />