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C� WELL PERMIT APPLICATION FORM SITE <br /> AUG 9 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> t1EAUNIT IV <br /> LfH ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> PERPpTISERVGES 304 E. Weber, Third Floor, Stockton, CA., 95202 ���� ��� <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEO <br /> appliratlon 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 /> :oaquin County Development Title,Chapter 9-1115.3 and the�S�tandards of San Joaquin County Public Health Services.Environmental Health Division. <br /> n 11 II-- Assessor's <br /> WELLLocation HisiAS¢A Rc'- A Gros S SCL*-5 city Ternc Zip Parcel# <br /> PROPERTY Owner C7JIL'J(u�t I 31�I�Lre��D3'fldtlress� " Ct 51 b City W <ts Ip9 Phone#yZS`��"}-�� <br /> C-57Contractor C.60AA Yr IAW"' Address ,c'� 1 CI ic#�ne#�.f <br /> Consultant/Sub Contractor IT-(d✓O,iar�_Addrass¢((b� V,�''` �C�rnJ Cit �EV1Gld Lic# Phone# Z�� 2g�"�lfitf <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED- <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,YAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> SOIL BORING# / D OVER-BORE <br /> D WELL# v [)PRESSURE GROUT <br /> Other. it A 41 <br /> Gro Spedfica'ons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE L)I)1 MULTIPLE CASINGS?DYES !NO W ELL CASING DIA:^ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE ,PUSH POINT GROUT SEAL PUMPED: D Yes ON. (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> p SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: D OTHER APPROX.BORING DEPTH tt D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROP SED? (if YES,list specifications here): <br /> 'COMMENTS: CAloStAwooD , <br /> NOTE: OFFSITE BORINGS RE IRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance. les and Regulations,and all applicable California State Laws. <br /> Signed x lI TtlelCompany �cmOC p���� <br /> Print Name w` Date <br /> DEPARTMENT USE ONLY C NOIV-it& <br /> SITE MAP IN UNrr IV FILE,ADDRESS: „NrlNSE/II t �✓ -5:.' y <br /> WORK PLAN DATED: V <br /> p X <br /> Application Accepted By Data Issued •� / Area O�v <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By _ Date <br /> COMMENTS/CONDIIONS: _ <br /> - ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'0 BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 o f 156 9:91/(0 -/O' I SRUVZ Z <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br />