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• • -COPY <br /> v� Cu'. WELL PERMIT APP'L'ICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> Cr C 0 7 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> F I _ H (209) 468-3449 OFF/ "SfoG PAc��c <br /> Ft,,: <br /> S T�� -- P,\Uj — <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 Health <br /> Division. <br /> rs <br /> WELL Location J��S,� YDCI y-�G ,4V2 Cross Street Q UTr$ City S'{-o Gkto-% Zip rj20 Parcel# 108-/60-tel <br /> Sart 3ba wV% Cityzip Phone#jQQ�Sy'�u'S <br /> PROPERTYOwner� /i-n Q$nllraP _Address SaYriP <br /> C-57 Contractor C Address,fl�t7 5t" .,(rte>t_city CtOT1zip 56 is#/7oZy0�'hone# 6 7pTL- <br /> Consultant/Sub Contractor Fr)Vlt0))rlptttlj 4 1Address��0/T (�rte4� WdGity IroLic#1Y A --kphone# -oV <br /> GIS Coordinates:X <br /> y ,Township / Range Section <br /> WORK TO BE PE ED: DESTRUCTION(choose type below) <br /> NEW WELL I ORING CPT,GEOPROBE,HYDROPUN 'HAND-A GER,OTHER') 0 OVER-BORE <br /> SOIL BORING# 0 PRESSURE GROUT <br /> W ELL# <br /> *Other: <br /> Grout Specifications, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �� MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE <br /> Q EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC OOTHER: <br /> 0 VAPOR - MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R'SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH_ Ifo �P�L� <br /> ,t CON UCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: tZ7uC <br /> NOTE: OF ITE 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 'nances, Rules Ind Re ulauons,and all applicable California State Laws. p n <br /> Title/Company ( O�b�L�s�[ /Ci7'u�'"� s'h'` cK.c <br /> Signed x —-� ,2 _ <br /> Date <br /> Print Name DEPARTMENT USyE,ONLY p <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PIAN DATED: /Z-(v -o/ <br /> DateIssued l Z - Area a <br /> Application Accepted By Date <br /> Grout Inspection By <br /> Date Final Inspection By <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 /> 350 <br /> 7 - DOZ Zf6Z- <br /> C-5 — WC=WAIVER^ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />