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WELL�'ERMIT APPLICATION FL M SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION {P S-EHD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 _ <br /> (209) 468-344 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y AR FROM DAIS ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install tie work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and tie Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 1� �" Assessor's <br /> WELL Location L.lNco�yt �j� Crass Street CYIHvcyt Sf Cit 5+00 - oYj Zi 52y <br /> ..... Y p � 'J Parcel# <br /> PROPERTY Owner___ KCTyt t ptaS o Address 1145 W.ckaV{,rvV4 City *z 4 i 47 Zip j5ZOV Phone# IWZDV}--4-x}2 <br /> L 3233�,i-�erwl ho G57ss�9yq, <br /> C-57 Contractor Wc%54 fIAZYYIgT Address 3wdc Ci Cordayq �s zip ,+2.Lic# Phone# �1p 4,74- VIII <br /> t55� BSc s}- Irrnrryv�li� CO3u17o'7 <br /> Consultant lSub Contractor- [CC'S Address K►11+ 4= City Lic# Phone# `5117 (p-S2-Sza.7_ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VNEW WELL/BORING(CPT,GEOPROBE,1 YDROPUNCH HAND-AUGER,OTHER- a DESTRUCTION(choose type below) <br /> 0SOIL BORINGNv-I Nb-,2. []OVER-BORE <br /> B WELL# 11 PRESSURE GROUT <br /> Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING p HOLLOW STEM DIA.OF BOREHOLE ULTIPLE CASINGS?d YES p NO WELL CASING DIA: <br /> 0 EXTRACTION g AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL B PVC BOTHER: <br /> 0 VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [1 AUGERS OHOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING (1 HAND AUGER GROUT SPECIFICATION <br /> OTHER: V.;.,4 P3, 0 OTHER APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPO ED? (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 thework will be done in accordance with San Joaquin <br /> County Ordinances, State La and Rules and Regulations of the San Joaquin County. <br /> * CALL THE IV INSPEC O 4 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed Title1Company . C YIMc. " e— <br /> Print Name C-4 eovl Date v <br /> SITE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By c - Dale Issued t Area <br /> Grout Inspection By Date I 7 "r Fin I Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3S6S a d 7 <br /> C-57 WC/WAIVER C-57 Letter of Authorization to sign ermit Encroachment doc 7/17/00 <br />