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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES " <br /> ENVIRONMENTAL HEALTH DIVUNIT IV <br /> DIVISION (PHS-EHD) <br /> t ;w 3D4 E. Weber', Third Floor, Stockton, GA., 95202 <br /> - (209) 468-3449 <br /> T~ <br /> NO PERMIT EXPIRES i YEAR FROM OATS ISSUED <br /> application Is hereby made to San Joaquin County for a permit to construct and/or instal the work described. This application is made In compliance w.Eli San_ L} <br /> Joaquin County Development it@e,Chapter 8-1115.3 and the Standards of San Joaquin County Public Health Services,Environments Health Division.Zs O I S <br /> 3 as W , c�vy-1.. S'I Cross Street O°`�C , Clty Parcel <br /> t 3 S i <br /> NELL Location; S 1 <br /> 1 3 2 5 W' �tt-►ti.o,� City Zip`�5 41 Phone# ��5- 80 <br /> PROPERTY Owner L�r`5a^ Address a1S�y� ,-1-Za°1�`� <br /> � b Qo L City s4a.Zip lic# Phone#�tb-"i <br /> C-57 Contractor V�W \`� Address <br /> r,cs <br /> oonsuttant I Sub Contractor C t .9.% Address <br /> Township Range Section <br /> GIS Coordinates:X Y <br /> WORK TO BE PERFO ED' O DESTRUCTION(choose type below) <br /> i]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER") Q OVER SORE , <br /> U SOIL BORING-4� PRESSURE GROUT <br /> IIWELL# <br /> 'Other. Grout S*Ifrcations: <br /> COMMENTS: a C—: '� c�C_ ;-'�-�^• <br /> TYPE-OF WELL iNSTALWTIONTYP CO T UCTIO SPECIFICAT[oNS <br /> SMONITORING ij HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?11 YES a NO SWELL CASING DIA <br /> OTHER: <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ©STEEL R RVC. p <br /> [j VAPOR ©MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS O'HOSE <br /> p AIR SPARGE t]PUSH POINT GROUT SEAL PUMPED: Dyes a No (NOTE: MAXIMUM FREE-FALL DEPTF(IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: - } <br /> Q OTHER: OTHER APPROX BORING DEPTH 1]BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,fist 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 Ordinanc les an 11tions,and all applicable California State Laws. <br /> Signed x <br /> � Title/Company <br /> Print Name <br /> Date Z., <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: . <br /> a <br /> g114 <br /> Application Accepted By Date Issued <br /> Grout Inspection By <br /> Date FinallnspecnonBy Date d� <br /> Destruction inspection By Date <br /> COMMENTS!CONDMONS: <br /> ACCOUNTING ONLY: A16# <br /> PE CODES FEE{NFO AMOUNT REMITTED CHECK# 'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> . — —i ] <br /> T Oo <br /> a 3o6{� <br /> C_57 WC R-WAIVEC-57 Letter of Author' at' n'I sign permit,Encroachmerit doc 0/27/00 <br /> 't <br /> 60 39Gd i NOO-1-� HlJId E6E89b60Z '9s:ET . T00z/8z/Z0 <br />