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J !� <br /> U <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> �J ENVIRONMENTAL HEALTH DIVISION (PHS-EHD} <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 488-3449 <br /> NON-REFUNDABLE PERMfT EXPIRES 1 YEAR FROM DATE ISSUED <br /> implication 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 /> :oaquin County Development Title,Chapter 9-1115.3Land the Standards of San Joaquin County Pubic Health Services,EnvironmenAssessotal l�sDivision. <br /> 'r <br /> -e< T Cross Street M If!;/o , of ity r c r� Zip f C3 3 1 Parcet#�1 q-3f-p' 3`? <br /> +YELL Location 110 <br /> 'ROPER1YOwne c. / Address c, I �'1�� �/ uN a<� Cffy� tiI[u+rc✓�_Z9p`Ts`Y I Phone# ��S "SCSS <br /> E <br /> -57 Gontractar�„ t ;i H Address 63 .�i� C r CitY�uN�I�°lc"�`'uZipgQILic# !7 75�� .Phone#�jG <br /> ty r h. lc.elwfl.ic# Phone#qlE- `�£/-b`/c�c7 <br /> i 4 <br /> '.onsultant/Sub Gontractor r`l�l - _Address"301 _hc 00 <br /> i <br /> 31S Coordinates:X <br /> Y Township 'I Range Section <br /> NORK TO BE PERFORMED: �> DESTRUCTION choose type below) <br /> 7 NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER ) § (choose <br /> []SOIL BORING# •@`PRESSURE GROUT <br /> [1 <br /> WELL# <br /> Grout Specifications: <br /> *Other: w P s <br /> COMMENTS: 1 0,,-� � S� .t vrr� v Y r.i lr'T. F <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING e HOLLOW STEM DIA.OF BOREHOLE_j -- <br /> MULTIPLE CASINGS?BYES [kNO WELL CASING DIA: -� <br /> B EXT_RACTION B AIR HAMMERIDRIVEN CASING THIGKNESS Sch TYPE O1 TYPE TO BE USED:V B AGUGERSR IT HOSE <br /> )R MUD ROTARY DEPTH OF GROUT SEAL C = TREMtE <br /> , No (NOTE: MAX <br /> a At SPARGE p PUSH,'POINT <br /> [MUM FREE-FALL DEPTH 1S 30') <br /> GROUT SEAL PUMPED: �Yes� - a i �Ile✓1� <br /> [}SOIL BORING B HAND AUGER GROUT SPECIFICATIONS: Sr ,1 BOLTED TRAFFIC BOX or ©STOVE PIPE <br /> B OTHER:_0 OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? N,0 (if YES,list specifications here): <br /> "COMMENTS: IJA W- 1 M w - 3 <br />'t 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 Ordinances, Rules and Regulations, and all applicable California State Laws. ` <br /> e�,Ic <br /> / /7 Title/Company Signed x :camPrint Namea is Date <br /> DEPARTMENT USE ONLY <br /> i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: !` <br /> WORK PLAN DATED: 3 <br /> Application Accepted By Date IssueArea_. <br /> d_S/� �— _ <br /> Grout Inspection By Date Final Inspection By Date. <br /> Destruction inspection By Date A <br /> i <br /> C01111MENTS 1 CONDITIONS: <br /> f <br /> --60UNTING ONLY: AID# Fermi 1 <br /> PE CODES FEE INFO AMOUNT REMriTED CHECK# REC'D BY DATE 1 PERMIT I SERVICE REQUEST# INVOICE <br /> � 3�y <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permits Encroachment doc 9/27/00 <br />'t s <br /> f <br />