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T <br /> �► FILE COPY <br /> WELL PERMIT APPLICATION FORM 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 <br /> �Services,Environmental Health Division. <br /> 36a i T IC 6 h Cr ~ty �*C i� y, p crSd 0 Parcel#cMs)- )-70 -thy <br /> WELL Location Qc t(. � Cross StreetLo /n /c'r�J �Ct i L Zi 1 <br /> PROPERTY Owner 5f N10 - Address 5 30F rrPaaci PZ( 4aciv �cl`for\ Zip�Phone# dO ?w-61 Z / <br /> C•57 Contractor �✓ �tlllK Address/��Uv ; �t /_C;ty )FfU✓I Zipj&r (Lic# OS'U Phone# ; �77p"C7lI� <br /> Consultant/Sub Contractor �VlKw nM'P4fu1 l744fldress /UC' f% "City CPu&Llc#po63`� Phone# 1y -O J�� <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 /> 0 SOIL BOR G# 0 OVER-BORE <br /> 0 W ELL# L -�1i _ W ' 3 D 0 PRESSURE GROUT <br /> T <br /> *Other: '—Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ��11 <br /> XMONITORING (jq`HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?0 YES KNO WELL CASING DIA: ar <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS Sc�a 0 TYPE OF CASING: 0 STEEL klt�VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .•2S-H f TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: Pe/$.(� 0 Nyo �(NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: &-✓CY-�O�-r r'e <br /> 0 <br /> OTHER:_0 OTHER APPROX.BORING DEPTH q-5 -66 X'BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /1/,6 (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 O Inances, Rules and Regulations, and all applicable California State Laws. }}','' <br /> Ylki ,a ,e,,CGS l7 ° <br /> Signedx R �✓'/1� -/-D"'�'�-�— �O rlfS Title/Company /V'�•O✓1 s� �C <br /> Print Name IJ/�'e�'1� f� �� UC[ ✓1 �/ 6'K Date (V13 ZOI <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 56;010 <br /> WORK PLAN DATED: 2—S—O <br /> Application Accepted By Date Issued 2^ �"' ^V I Area D� u <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> g I-I'J' DO <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br /> FILE COPY <br />