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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHSMEND) <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 /> e lltt SDivision. <br /> WELL Location (all` No 1�TuI Cross Street Oakt % , City SkCVk"1 Zip Parcel# <br /> PROPERTYOwner ���I FctrvtA C/ Address 315Lo F®.(f Mt U, City �40C.IL1-cam Zip LLL ) Phone# Y51, - ) " 'Q <br /> C•57 Contractor Address �-° 33f. City k`0 w (V Zip 44151-1 Lic#1406I Phone# X1' 3fq - 4)aQ <br /> Consultant l Sub Contractor X-v, AddreW 111 Lnz*� - ArAl ^ City htAt)4A b Lic# Phone# 5 " <br /> GIS Coordinates: X <br /> y., TownshipRange Section <br /> WORK TO-BE PERFORMED: DESTRUCTION (choose type belay+) <br /> EWWELL / BOR <br /> VING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') [I OVER-BORE <br /> SOIL BORING # - fl PRESSURE GROUT <br /> 'Other: WELL # 3 Grout Specifications: . <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING )kHOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 1] YES k NO WELL CASING DIA: Z �r <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS S0wke 4z TYPETYPE OF CASING I] STEEL PVC 0 OTHER: <br /> ,VAPOR o MUD ROTARY DEPTH OF GROUT SEAL 25 TREMIE TYPE TO BE USED: 'geAUGERS I] HOSE <br /> ] +AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: [I Yes Mo (NOTE: MAXIMUM FREE-FALL DEPTH IS 300) <br /> SOIL BORING 1] HAND AUGER GROUT SPECIFICATIONS, -'M'�`� O'yt'r OL TED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: II OTHER APPROX. BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? )JO ( 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 Ordinances,ncules and egulations, and all applicable California SAtate Laws. <br /> Signed x <br /> b✓� Title/Company k- L Ar S %wz. La4 <br /> � <br /> Date <br /> Print Name f QW UAvV QL�tti <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> d Issue <br /> C VC) / Area`- ' <br /> Application Accepted ey Date Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection B Date <br /> COMMENTS I CONDITIONS: Mimi 111 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D Y DATE PERMIT I SERVICE REQUEST <br /> UEST # INVOICE <br /> C) � �55 @ � � 2 <br /> C-57_ WCWAIVER_ C-57 Letter of Autho Iz to sign permit_ Encroachment doc= 9/27/00 <br /> = <br />