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' r <br /> WELL PERMIT APPLICATION FORM <br /> 1 <br /> [R�= <br /> rr _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION 6 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ' NOV 0 7 20304 E Weber, Third Floor, Stockton, CA , 95262 <br /> (269) 468-3449 <br /> Application is hereby ��I w;{'' �,ti r ; NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �UnO <br /> Y �to ar Jaaquin Cflgrtity fora permit to construct andlor install the work described This application is made in comps:ante with San Joaquin County <br /> Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County PublTc Health Services Environmental Health Division <br /> WELL Location r� Ro b!K k o0� <br /> C iG V Cross Street_ Dr Cfty Strdcl.t-oH Zi J2U Assess20 <br /> �f-� n --�T. p Partes# p <br /> 'PROPERTY Owner�LO)l e' J-'p•a Address Jr�r�C�r Ire CityJ�=UGCttCi,^^Zip $ p Phone# Cf~l.52 -�2 <br /> C 57 Contractor rl 111 Y! Address 2 f(9 City a 10l� <br /> ..LL� /Phone# <br /> Consultant 1 Sub Contractor "-vi kV—+ •-Lk Address oo/Q C <br /> " ftY <br /> 'GIS Coordinates X Y TownsNp Range 9 SectEon <br /> WORTS TO BE PERFOR <br /> ANEW WELL!BORING CPT GEOPROBE HYDROPUNCH HAN -AUGER OTHER') <br /> SOIL BORING# �' t�7"— [1 DESTRUCTION(choose type below) <br /> ' 1)OVER-BOPE <br /> -Other WELL# ` 0 PRESSURE GROUT <br /> COMMENTS Grout Specifications <br /> TYPE OF WELL INSTALLATION TYPE <br /> CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA OF BOREHOLE I MULTIPLE CASINGS7 0 YES ONO WELL CASING DIA <br /> n EXTRACTION d AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING a STEEL 0 PVC p OTHER <br /> Q VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED <br /> p AUGERS p HOSE <br /> 0 AIR SPARGE &PUSH POINT GROUT SEAL PUMPED Yes 11 No (NOTE MAXIMUM FRVE-FALL DEPTH IS 30`) <br /> SOIL BORING DHANDAUGER GROUT SPECIFICATIONS uliailicm-^ <br /> HER_0 OTHER APPROX BORING DEPTH QT 0 801-41D TRAFFIC 80X or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ([ YES fist 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 County Ordinances, <br /> Rules and Regulations, and all applicable California State Laws <br /> Signed x TitlelCompany <br />,Print Name Y Date_ <br /> DEPARTMENT USE <br /> cc ONLY <br />`SITE MAP IN UNIT IV FILE,ADDRESS d(0 � "rZ <br /> WORK PLAN DATED <br /> Application Accepted By Date Issued <br /> �? <br /> Grout Inspection By Date Area <br /> Final InsoeChnn By <br /> Mitt! <br /> Destruction Inspection By Data <br /> COMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD 6Y DATE PERMIT!SERV]CE REQUEST# INVOICE <br /> 3��1 9 � Z(Q l��7 O 1 SIR QOZ$0 � <br /> C-57L— WC--WAIVER_ C-57 Letter of Authorizatmn to Sign permit Encroachment doc� 9/27/00 <br />