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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. Weber, Third Floor, 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 and/or install the work described. This application is made in compliance with San <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 /> u�I 4 Cross Street y/1 101ti - City S o ZiP Parcel# <br /> WELL Location j Z. r�4 I^ �' i <br /> PROPERTY OwnerCr,S i r.^v+ 3aWtkrs d v QX ��� CityM�Un+�Gn 2�Z PPhone# 2 G 9 ►5'y!jl SS <br /> �O�d fA�G��L1-zL( Add\ess B OA 3� City Q!d 1/1 Sty--Zi&9f*? Lic#7/Gd Phone#�U7 <br /> C-57 Contractor 1 A <br /> Consultant/Sub ContractorATC- A<Sac1ti Address ///-7Loi,tPG�.. 4�j. City�l,�n� Lic# Phone# Gni 579-�Z2 <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type beIV) <br /> j�W WELL/BORING(CPT,GEOPROBE,HYDROPUNC ,HAND-AUGER,OTHER-) 0 OVER-BORE <br /> ,U SOIL BORING# (I PRESSURE GROUT <br /> [}WELL <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 41-MONITORING 41-6 6LLOW STEM DIA.OF BOREHOLE �t� MULTIPLE CASINGS?�YES �10 WELL CASING DIA: _ <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS YO TYPE OF CASING: []STEEL t$Pt1C .0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL 32 / TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: %li—Q,� <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH SS t" <br /> OLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NO (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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count?Ord"inZan es, Rules and Regulations, and all applicable CaliforniaS�t�aate LawsSigned xTitle/Company // /CPrint Na �4 -c/( r1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued �-�L i--��� Area <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> [IPE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> g 0z i 3 z( <br /> C-57 WC -WAIVER C-57 Letter of Authorization to n er it Encroachment doc 9/27/00 <br />