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l <br /> WELL PERMIT APPLICATION FORM SITE <br /> pEAMITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEkftt .f?ViCF UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (aI�H[ ) AM 10: <br /> 27 <br /> 304 E. Weber, Third Floor, Stockton; CA., 2 <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 and/or install the work described. This application is made in compliance with Sari;. <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental <br /> Health <br /> Division. <br /> / �, Cross Street >�City �UZIp <br /> ' /d Parcel# <br /> WELL Location <br /> PROPERTY Owner�p✓-4 /l`��LG/ Address 76 l �/&�' City ��e.{�o Phone# F�SJ2 �a <br /> ate- City i ! rLLic#7/170 Phone# � " IA% <br /> C-57Contractor ,4/. AddressZ <br /> Consultant!Sub Contractor (�[/ AddressI/1 I�L�r� City CoeG1Ar�Cic# Phone# g/-o60G <br /> FGIS Coordinates:X - ,Y- - .,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> [I NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,-HAND-AUGER,OTHER") a AVER-BORE <br /> []SOIL BORING# <br /> 0 WELL# r; PRESSURE GROUT <br /> 'Other: Grout Specifi tions: <br /> COMMENTS: Z10 <br /> TYPE OF WELL INSTALLATION TYPE- CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[I YES a NO WELL CASING DIA: <br /> Q EXTRACTION '[]AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL H PVC 0 OTHER: -: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> p AIR SPARGE JI PUSH POINT GROUT SEAL PUMPED:: 0 Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> r <br /> a SOIL BORING 0 HAND AUGER- GROUT SPECIFICATIONS: <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CA5ING PROPOSED? (if YES,list specificati Qns here): <br /> "COMMENTS: T-L> 136- t t.-. (1%,% <br /> 7l YLi.. E I S I�S TS <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, ules nd Regulations, and all applicable California State Laws. <br /> Signed x �1 �,, (� Title/Company <br /> Print Name GGl Date. . <br /> DEPARTMENT USE ONLY <br /> I <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PIAN DATED: <br /> . 1 <br /> Application Accepted a Date IssuedW//I D Area u'P <br /> Grout Inspection By .. Date 0 Final Inspection By Date <br /> r <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> Gerff <br /> PE CODES FEE INFO AMOUNTREMITTEDCHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br />'' S.oz [r v Imp 11 d3 SRU 00? e <br /> C-57 WC -WAIVER C-57 Letter.of Authorization to sign permit Encroachment doc 4/2.7/00 <br />