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• t • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 andlor 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 /> r [1r�lc � nhto-1 Assessors <br /> WELL Locationf- rr�� /'j' CrossStreet <br /> (i�)r //,� City stocL�t-'% Zip�7 2v7Parcel# X07-'27c7- <br /> 08 <br /> PROPERTY Ownier) -7 Y1K tli2. Address _l�t)od' azL,�.c Ate City) cl Zip r : hone# 0 , Z_ ^7-7 <br /> C-57 Contractor�kegL 176s wn t Address U3 FtZ�eedj) �''A»� 7 T`� <br /> rI �� City `. _ :'i ZipZLic#�i:y y`7 hone#3%iL-%G3c�/"727✓t, <br /> Consultant/Sub Contractor �ii�'r tL^-rhxlr.i �tTYC(,�Address Q�"�'t � ' .oily 'lCceN is#I:YF-�`,` Phone# 1' 3&)-f5�/ <br /> GIS Coordinates:X 'Y ,Township ` Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> n SOIL BORING# 0 OVER-BORE <br /> Yd <br /> WELL# /�. 2 0 PRESSURE GROUT <br /> 'Other: (� _T^ - - - - n Grout Specifications: <br /> COMMENTS: L - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ry <br /> 0 MONITORING `HOLLOW STEM DIA.OF BOREHOLE r` MULTIPLE CASINGS?0 YES AND WELL CASING DIA: � _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sy-I¢,I L/O TYPE OF CASING: 0 STEEL0 PVC 0 OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 61 TREMIE TYPE TO BE U ED: []AUGERS 0 HOSE <br /> VAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: YZ7?v r i <br /> n OTHER: n OTHER APPROX.BORING DEPTH 7o 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?VC._(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 <br /> County Ordinances, <br /> Rules and Regulations, and all applicable Californian State Laws. <br /> Signed Ce,113 -t- Title/Company <br /> Print Name )i, ?e3t lt� Cl1.,�; 'vA Date 310 ^G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0( <br /> WORK PLAN DATED: (O `0 <br /> Application Accepted ByDate Issued C a Area Dt✓v <br /> Grout Inspection By Date 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 /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />