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• • 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 L <br /> (209) 468-3449 Q�F' C(6lxoa) <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 Tile,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> S;a(Z �( L h 2 k city 5 i, SJ �p ssessors <br /> WELL Location $606 c;rr tC �l Crossl,Street '/d b1-/n Ce; Ci S/QG � Zi c! D arcel# <br /> PROPERTY Owner l: t d Ir S�CCt 1�+'�Address I�J�N�,c__�/��0✓eju city S CLGt RT1 zip 'Phhone# Of 937Fj633 <br /> C-57 Contractor HI 114 Address r(� SSL L',�( L Ci /2f0- ,Z�ipCsb Lic#``,,'hone#��b 7 - 0'f) <br /> Consultant/Sub Contractor 1:VIP i^Un�x/Q'�'14.Cril Address IM- dmf ity ,gC A Y\ Lic#Or-'6.3`� phone#7� I Y5�� <br /> GIS Coordinates:X 'y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORN G# `/ 0 OVER-BORE <br /> WELL# V- <./") CU"6p U O PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �1 <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE jq, A) MULTIPLE CASINGS? YES ONO WELL CASING DIA <br /> LL,,�� <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS SchoJ 46 TYPE OF CASING:: 0 STEEL p,PVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL�o/` fill ' TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ��L-I"fJ"cc C <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH FJrr' /0 S ;BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?,,&/0 (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O finances, Rules andl/1R�e/g,LU�{lotions,/andlall applicable CaliforniaStateLaws. 1 �[/ <br /> Signed x J`-'(/��'^"" (Ju 10 L$ Title/Company -C tit.U(VW" 1vL`e;.l. 'Z I '4e',/'Cf <br /> Print Name t ecv Date 6�/ L3/V / <br /> CDEPART ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ✓4?0(0 <br /> WORK PLAN DATED: '5 <br /> Pq <br /> Application Accepted By Date Issued 2^4O-0/ AreA <br /> Grout Inspection E Y Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 56 -� <br /> ACCOUNTING ONLY: AID# FArtt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3so� �z z-l3 -SR# �a2sz� <br /> C-57_ WC=WAIVER — C-57 Letter of Authorization to sign permit_Encroachment doc-e:!� 9/27/00 <br /> FILE COPY <br />