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I 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) 46&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 Health Division. <br /> ff t Assessors <br /> WELL Location �Lt�I�U� yiJ '�9V .n SF Cross StreetrV S�' �Clty S{aCI[.(-I Zip Parcel# <br /> PROPERTY Owner Uj,:j t S)Ik+C.LZ-4b Address3ZS V , &l City L4!V9 . 10 " Zip Phone# 4 �} — � 3 (p (� <br /> C-57 Contractor F'` CIA E-AV Address 3� q S�1ts 1� 1oc> city Vc l� T - rp `�5' li7rc# 6�Whone# <br /> (kxL A-4 S , Address l l i �' (�A- pal v Clty AL bekl: LickPhone# S <br /> Consultant I Sub Contractor ' <br /> GIS Coordinates: X <br /> Y , Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type bel4y+) " <br /> `�WNEW WELL / BORING ( CH T, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') OVER-BORE <br /> H WELL # <br /> �, L BORING # LAo PRESSURE GROUT <br /> Q WE - <br /> *Other" Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA. OF BOREHOLE Z MULTIPLE CASINGS? U YES [�Adb WELL CASING DIA:_ <br /> EXTRACTION 17 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL [IPVC Il OTHER: <br /> 0 VAPOR 1] MUD ROTARY DEPTH OF GROUT SEAL �Z S TREMIE TYPE TO BE USED: 1] AUGERS Il HOSE <br /> a AIR SPARGE �USH POINT GROUT SEAL PUMPED: N Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> *SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: 2 S BOLTED TRAFFIC BOX or p STOVE PIPE <br /> a OTHER: [I OTHER APPROX. BORING DEPTH D <br /> CONDUCTOR CASING PROPOSED? ( 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,rRules ano Regulations , and all applicable California State Laws" I <br /> Signed A v Title/Company kTc <br /> a I-Ll z�fAI <br /> Print Name - T "" C`v` ' " �'� _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED ' 9 <br /> Application Accepted By ✓ ate Issued �-P ( � Zoa / Area. <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By ate <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMrr / SERVICE REQUEST # INVOICE <br /> C-57�I WC.-WAIVER. C-57 Letter of Aorizat}' n� sign permit_ Encroachment doc_ 9/27/00 <br /> V <br />