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WELL ftRMIT APPLICATION FO M SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 Health Division. <br /> Assess r, <br /> 2`7(� F-_1. I p"17�5 Parcel# ) 'J��rZl7C7 <br /> WELL Location I" Cross Street �'—City »uGfC..'" Cq1 Zi <br /> PROPERTY Owner&t7 <br /> )r or^a Address I P 3lo SiCf%r�1UZ� 1�1. City S �fb I [\Zi� Phone# <br /> C-ST Contractor �S L�Qe , f 7 Phone#� (0 D3 a �lD��L 6 <br /> J � 6 .�D � k �) �, �� City �is# Phone#9/&0 ( `Consultant/Sub Contractor <br /> SJ,3C J�71� <br /> GIS Coordinates:X 'Y\ Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> SOIL BORING# []OVER-BORE <br /> WELL# M iN —H 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE S f_ MULTIPLE CASINGS?1]YES ;WNO WELL CASING DIA: 2 )' <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESSSGk LIO TYPE OF CASING: Q STEEL PVC Q OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL-'5!5' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: )jYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: Nis 14']' G q—y'l e✓1't- <br /> Q OTHER: n OTHER APPROX.BORING DEPTH ^-(DS 1 0 BOLTED TRAFFIC BOX or ASTOVE PIPE <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances. Rules and Regu�s, and all applicable California State Laws. / <br /> Signed X Title/Company !S F— t�✓"b e.0 t °Vl fi <br /> Print Name Q Date .`l l v2 j <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Dat sue Area <br /> Grout Inspection By D.4 e Final 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/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC -WAIVER C-57 letter of Authorization to sign permit Encroachment doc 9/27/00 <br />