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0 0 ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> 1�1,=.i,; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> NOV 0 7 20004 E. Weber, Third Floor, Stockton, CA., 95202 tl <br /> (209)468-3449 l� 1 <br /> ENVIROi�;v1 ;.? `,_.. IH SYao <br /> �rC01/.r.,.� NON-REFUNDABLE PERMIT EXPIRES IYEAR FROM DATE ISSUED <br /> Application is hereby mar�e�a•ua�/Joaquin Count for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> //'' P RobiKkood. As essnrs <br /> WELL Location ;T� Crt-Vnr�C J4V'e Cross Street <br /> [7 Dr AACity$tool:to 11 Zip `JZV Parcel# /o2-2OVD-.�.0 <br /> PROPERTY Owner Sto)l IINJ Address 5308 POP r il.0 hV2 CityROC.I!l Zip 95;L07 Phone# 209 ?5.2 -62-T7 <br /> C-57 Contractor G' ri It];j <br /> Address�_1950 Hft. e Rd City artln p S63 Lic#/a56�/,oef7Phone# 5 /3-5804 <br /> Consultant/Sub Contractor Cnvr Yr.M•MPH r..al A4c� ddress I60 �itY QCPntt Lic#6C635OPhone#7/iSra� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORM <br /> ANEW WELL/BORING CPT GEOPROBE,HYDROPUNCH UGER,OTHER') 0 DESTRUCTION(choose type below) <br /> SOIL BORING# CPTH'-i DOVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> •Other: 1 Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI ATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE I MULTIPLE CASINGS?D YES PO WELL CASING DIA:_ <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE kLPUSH POINT GROUT SEAL PUMPED: p Yes D No (NOTE: MAXIMUM FIR E-FALL DEPTH IS 30') <br /> SOILBORING aHAND AUGER GROUT SPECIFICATIONS: Ueon-" y( <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Regulations, <br /> and all applicable California State Laws. LL�� <br /> Signed x_k/irm t-- hh TitlelCompany C�s�� <br /> Print Name m['c.�I am Date !l-OG -D/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 56 06 <br /> WORK PLAN DATED: /O *Vr — R-ea -0/ <br /> )r <br /> Application Accepted By � Date Issued /� �0 / Agre�a, 0 b <br /> Grout Inspection By Date Final Inspection By - ' ■ DM� Z <br /> G' —.�-+ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> `350 � 191- ,/ <br /> 1 <br /> • Yf2(o //-7-0 1 SR# a0Z80?` <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />