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PERMIT APPLICATION FM <br /> WELL SITE <br /> ;i MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT 1V <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> I� 304 E. Weber, Third Floor, Stockton,) CA., 95202 <br /> (209) 468-3449 <br /> 3 . <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 /> Assessors <br /> WELL Location 1 _ .t r Cross Street ei1„s� , City S f�c�{e i� Zip I Sa�� Parce <br /> ri ,C, E l Ce N 'I € i <br /> PROPERTY Owner Ghtv,�.��a��N+�r LgrPr�rt��c�A �ess C�pCv 1 �e��.r Pr �"' City 54 �u,un _Zipq'1SS Phone#�1aS'�'J res <br /> uH <br /> � rNu _ <br /> 7 S-! <br /> C-57 ContractorC.r ---,d—,.-J—, Address 36 52 e,' �c ei i� Z Clh'c, ,�{oy 4 Zip1�` 9 a Lic#7 17 O�hone# Ib <br /> r►I aO'IX16- 6/-a <br /> Consultant!Sub Contractor e1 Address !� f`+r!, cr e City !br" V't _Lic# Phone# <br /> 4 <br /> 3 � � <br /> 41 <br /> -5 <br /> GtS Coordinates:X <br /> Y Township I Range Section <br /> s <br /> WORK TO BE PERFORMED: i <br /> D NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> + )(DESTRUCTION(choose type below) <br /> ©SOIL BORING# ;-OVER-BORE <br /> D WELL# 0,PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: re 5S Cj r Q � f�� rr� � ; � ��r � i d �f r� Wel 1 S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> :l <br /> i. MONITORING D HOLLOW STEM DIA,OF BOREHOLE_ �r� MULTIPLE CASINGS?Q YES ;a NO WELL CASING DIA: v� <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS 5 cH D TYPE OF CASING: D STEEL '8 PVC D OTHER: <br /> VAPOR [)MUD ROTARY DEPTH OF GROUT SEAL j D TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE [I PUSH POINT GROUT SEAL PUMPED: R Yes D No](NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER: l OTHER APPROX.BORING DEPTH_; /, 7 !_ _©BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? yp (if YES.list specifications here): <br /> 'COMMENTS: /M\✓`�. M4✓�a: /yl 1N- W/ l� �P rl�s fro r P i r <br /> I� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ORENCROACHMENT PERMITS. <br /> i 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 Regulations, and all applicable California State Laws. ` <br /> Slgned z Title/Company E S$G / r� l S e?f r e:4 <br /> /jam t Q <br /> Print Name DaleDEPARTMENT USE ONLY <br /> 'i <br /> I ! <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 'I <br /> WORK PLAN DATED: ` <br /> I. <br /> I Application Accepted By Date Issued 2_ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: All?# �nr� <br /> PE CODES FEE INFO AMOUNT REMr TED CHECK# REC'D BY DATED PERMrr!SERVICE REQUEST# INVOICE <br /> 40�' SM y <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit d1 Encroachment doc 9/27/00 <br /> i <br />