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WELL PERMIT APPLICATION FORM �s✓y <br /> IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> li U "J 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> ' <br /> NON 0 7 2 0 01 (209) 468-3449 <br /> Al <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , • � J` <br /> Application is hereby made to San Joaqu+lt County for a oerm+t to construct and/or Install the work descr bed This appi+cat ort is made In compliance with San Joaquin r�6Q* <br /> Developii*0t6e Chapter 9-1115 3 and the Standards of San Joaquin County P/�ublic1city �Lot r ry N z+p c}'��U�Heaith Services,Envi.onmental Health Division County <br /> pp �)A Aiw is I-Q�r+' 1" Crass Street Rob� •IPU` <br /> WELL Location ssessors <br /> �j �r- parcel#_ _p Z— A2�`7--b <br /> PROPERTY Owner "E07! Address �Qe r Ve CityLLGG C)r\ zip Zphcne# <br /> C 67 Contractor G ri III r} Address J_0 1 b C� City �v�1� r $S3 LI (,O`b�f07 <br /> P5� !Phones q�Jr3'S8O6 <br /> Consultant/Sub Contractory0,,y,1eKta I A f_&ddress_ <br /> GIS Coordinates X Y Township ] Range Section <br /> WORK TO BE PERFORM <br /> ANEW WELL/BORING 0 GEOPROSE HYDROPUNCH HAND AUGER OTHER'} <br /> 0 SOIL BORING# CITY 0 DESTRUCTION(choose type below) <br /> I-COMMENTS <br /> Otttcr 0 WELL# I]OVER BORE <br /> �� PRESSURE GROUT <br /> Grout Specifications IJ <br /> 'TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIE CATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE t MULTIPLE CASINGS?0 YES NO WELL CASING DIA <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS0 <br /> TYPE OF CASING I]STEEL 0 PVC 0 OTHER <br /> j]VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TD BE USED <br /> AIR SPARGE #PUSH POINT GROUTSEAL PUMPED 0 Yes p GAUGERS 0 HOSE <br /> No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPEGIFICATfONS <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH t <br /> _4.�� f 0 BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> 10MMENTS CONDUCTOR CASING PROPOSED? (If YES fast specifications here) <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 writ be done In accordance with San Joaquin County Ordinances, <br /> Rules and Regulations,and all applicable California State Laws <br /> Signed x <br /> +Ila/Company <br />,Pnnf Name Dafe `Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS 5106 Ge/a <br /> IWORK PLAN DATED /Q J <br /> Application Accepted By Date IssuedZZ— 1 -07 Area V� <br /> rout Inspection Bmt- y Date Final Inspection By Date <br /> egt,uction 1,,sp �t n m, <br /> Gate <br /> COMMENTS I CONDITIONS <br /> LPECODES <br /> NG ONLY AID# <br /> FAC# <br /> FEE INFO AMOUNT REMITTED CHECKtt RECD 8Y DATE PERMIT!SERVICE REQUESTINVOICE <br /> 0. r 71i ��f� R# OZ D S <br /> C-57 WC�-WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br />