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CC( C �V�[ DD WEL•ERMIT APPLICATION FORM SITE <br /> FEB 1 9 20ENSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> VIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> 31n'11/J-� R -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 /> WELL Location Lln(„11r •t� 4'r e i Assessors <br /> Cross Street er t,- S�� CitySj6cxll-- zip g52o-L Parcel-- 137-3b-35 <br /> PROPERTY Owner S0(k>0n 2104-4-P-A r-*'Address Cly/ 0,1% oclt-�, zip c157,eZ Phone" <br /> City <br /> C-57 Contractor[--w.P,wj� Go5�-�t-&- Address 15�16 A\Kr,x Cily�� ay,, zip(��111ic#t1ay Z-s pryone#40�-Z$0-G,$a.1. <br /> Consultant/Sub ContractorL14Y';9n ' C O� I City <br /> �''`P Addressbg7p �(1lntcr P..k., City )[0nt0+ Ckic# - Phone#y2$y2(. - j-1 <br /> GIS Coordinates:X3l'Sl r btAh0 Y IZ' 1l/ y(,hW Township I?J RangeSection tl) <br /> WORK TO BE PERFORMED- <br /> 11 NEW WELL/BORING(CPT,GEOPRO8E,HYDROPUNCH,HAND-AUGER,OTHER-) O DESTRUCTION (choose type below) <br /> 0 SOIL BORING#WELL# OVER-BORE <br /> 'jMw-1 <br /> 'Other: GROUT SPECIFICATION 0 PRESSURE GROUT <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> III MONITORING Y HOLLOW STEM DIA.OF BOREHOLE 4T MULTIPLE CASINGS?0 YES M NO WELL CASING DIA:Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS50.Llt40 TYPE OF CASING: 0 STEEL <br /> r PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL el TREMIE TYPE TO BE USED: It AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes R No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION�QpF U/nC <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH ZS 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? he (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ` CALL T,(HE,UN'IT IV IN,(7gPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed / —?�11.../lw Title/Company_ 1" sfL• <br /> Print Name A414- Date -Z/14/07 <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> w <br /> Application Accepted By Date Issued Area , I <br /> Grout Inspection By Da Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> I PE CODES FEE INFO IAMOUNT]REMITTED CHECK# REC'D DATE PERMIT/SERVICE REQUEST# IN <br /> ZW330 a 3Z <br /> C-57_ WC/WAIVER_ C-57 Letter of Authoriz to to gn permit_ Encroachment doc_ 7/17/ <br />