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ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <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 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 Services,Environmental <br /> He lth Division. <br /> AssesWELL Location / PAG/F/t A✓ENr/E Cross Street RW11V11 O1o` City SToctseN Zip 9'5207 Parcel# <br /> CO[[ELE 209 <br /> PROPERTY Owner SANJOAgv/N DECT�l Address S'1'r/Y�` '4S WE[c City Zip Phone# 95'1 sass <br /> L�5 <br /> C-57 ContractorGREGL '�J .517-0 Address 950 HawE �Ga'1G City NAxr/NEI1ip fY539Li4wF one# 3T3",$'yDa <br /> dress /000-N OR' LA t.H PLA�E�rT/ is GO4J//8Phone# bt-'PSL/ <br /> Consultant/Sub ContractorEN✓Ae&07e � z �✓✓O/ iry '� # <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BEP M DESTRUCTION(choose type below) <br /> []NEW WELL 1 ORIN CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0OVER-BORE <br /> []SOIL BORING# <br /> n aa WELL# PRESSURE GROUT <br /> 'Other: (�D �. 7. Grout Specifications: T,aEMiE FAO/+' TEiC�Yi�'�1"'-iON <br /> COMMENTS: 7yd /Aee1��7 GC�n/ To L<NoE <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?BYES []NO WELL CASING DIA:_ <br /> []EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL []PVC [IOTHER: <br /> []VAPOR G MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: J]AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: U Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ©SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: <br /> []OTHER: []OTHER APPROX.BORING DEPTH_0 BOLTED TRAFFIC BOX or []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 <br /> County Ord]n nces, Rules nd Regulations, and all applicable California State Laws. <br /> Title/Company <br /> P.eE3/OEM- EN /RON/7ENf-R[ <br /> Signed x 41-10 iT <br /> // Date 7 0 0 <br /> Print Name ST6✓EN/y. ��/� � Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S � <br /> WORK PLAN D4By <br /> C) <br /> Application Accepte _ Date Issued �l"ea' Area <br /> Grout Inspection By DateFinal Inspection ByCON <br /> Destruction InspectiDate <br /> COMMENTS I CON <br /> 6ACCOUNTING ONLY: AID# <br /> ODESFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICEREQUEST# INVOICE <br /> 0355¢ 1-2 SR# fl02 `� S <br /> Encroachment doc G <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits N 9/27/00 <br />