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• • 0=2)V <br /> WELL PERMIT APPLICATION FORM SITE '� <br /> MITIGATI0?�1 <br /> SAN JOAQUIN COUNTY PUBLIC.HEALTH SERVICES 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 t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance whh San <br /> Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health <br /> sDivision, <br /> Cross Street City STocXreN Zip 95207 Parcel# /408"/iO�O! <br /> WELL Location=5-/-.75-1 PAG'/F/e '4y' E 210 C? <br /> GOdLEC£ S'.IhlE AS WE[G Cily Zip Phone# gSy-SOSS' <br /> PROPERTY Owner SAN J OAQfuN Ar,:7 4 Address 3Z o <br /> C-57 Contractor 6'�L L /N S172) Address ?SIP yGWe APIA City��!/N£LZip��/�3Lic� hone# 77 <br /> Consultant I Sub Contractor/✓+'/'e 'Y L 1/0/ <br /> dress 10976"1" TEL"r O� r..s'tity pLAee^''//�ic#(OLl�/BPhone# <br /> ` bt'YSL/ <br /> GIS Coordinates:X ,Y <br /> ,Township Range Section <br /> WORK TO BEP M • - a DESTRUCTION(choose type below) <br /> Q NEW WELL/ ORIN CPT GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER`) []OVER-BORE <br /> a SOIL BORING# o PRESSURE GROUT <br /> �q.,. o WELL# T,e£M/E P.e O.�r fin'/NT�bN <br /> �,Y/ a - � ' Grout Specifications: <br /> *Other: /'-- �� ,y pE/s1/ re <br /> COMMENTS /JaT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTTIIPLE CASINGS?PE OF CASING[ [JESTEOELOI] WELL[I SH RD : <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: II AUGERS [j HOSE <br /> []VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> [I AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: U Yes 1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'j <br /> [ROIL BORING O HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0OTHER: ()OTHER APPROX.BORING DEPTH <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 l have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nCos, Rules nd Regulations,and all applicable California State Laws. <br /> \ <br /> Title/Company <br /> P,eES/OE.vT E/V✓/�eaN�rEnrf'4e Arlo it <br /> Signed x /O 27 o 0 <br /> SsE✓EN • Date -- <br /> Print Name DEPART�ME�NT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: vV�' <br /> WORK PLAN DATED: d " <br /> Date Issued Area D <br /> Application Accepted By Date <br /> Grout Inspection By <br /> Date_ Fina6lnspection By <br /> Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT lR n Ct REQUEST# INVOICE <br /> CO2 <br /> 3Sca — "a �� �o( 9/27/00 <br /> C-5 — WC—WAIVER_.. C-57 Letter of Authorizationcoon to sign permit Encroachment doc <br />