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WELL PERMIT APPLICATION F6RM SITE <br /> MITIGATION <br /> ����� <br /> �AN <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICESUNIT IV <br /> FEB 1 3 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 2001 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRoj�'mENT HEALTH (209) 468-3449 <br /> PERN11T-SERVICES 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 Cougty Public Health Services,Environmental Health Division_ <br /> --,, W Assessor's <br /> WELL Location 1"70 t//�OY4Kk SG1G/Q Coss Street A" City ip Parcel# <br /> PROPERTY Owner Addressy City Q Zip / Phone# <br /> C-57 Contractorcity <br /> Z�hone# <br /> � �37 kfU �/ Cits6• <br /> CiLic# DbZZ <br /> Consultant/Sub Contractor //I61 � 1140 Address 115A44 <br /> hone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPuNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> SELL <br /> #�3 0 OVER-BORE <br /> ELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Z�I MULTIPLE CASINGS?0 YES YE <br /> NO WELL CASING DIA:0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: 0 ST0 PVC 0 OTHER: 1U� <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ZS TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Q Yes GAo (NOTE: MAXIM/UM FREE-FALL DEPTH IS 30') <br /> gSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:?DI�G�A C r V�-r 1 <br /> Q OTHER:_O OTHER APPROX.BORING DEPTH -Z-5— Q BOLTEe TRAFFIC BOX or []STOVEPIPE <br /> COND CTOR CASING PROPOSED? if YES,list specifications here): <br /> 'COMMENTS: ��ti <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 Or ' nce R nd Regul tions, and all applicable California State Laws. <br /> Signed x L Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ,, c <br /> Application Accepted By i�-�- Date Issued K I Uof Area £S A <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0/ o��s - <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />