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r <br /> S33IAH3S/llwH3d WELL PERMIT APPLICATION FURM SITE <br /> HIIVl 11 IN31NNOHIANA SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 1007 t T AdW ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> Q �I / i6`JICHI <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 Health Division. <br /> Assessor'- <br /> WELL Location `U/U/ / �(/4 G�Cross Street _ ty L zip <br /> Q �� <br /> PROPERTY Owner�r�� v�5' �h�i Apddres /.� City��� ,L Zip�r--„5==—.}Phone# �/,, <br /> C-57 Contractor��G Addressv 3 s Ciry�� YipG ( is#&VO-7Phone# I'� b� <br /> Consultant/Sub Contractor Address CityLic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> W K TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> a SOIL BORING# �OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEjULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR UD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE TUSH POINT GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING //f/0 HAND AUGER GROUT SPECIFICATIONS: n ��� <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH �(O r GC/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASIN 'PROPOSED? if Y list specifications here): <br /> *COMMENTS: I <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 Ordinances, Rules and Regulations, and all applicable California State Laws. „ <br /> Signed x_v_ Title/Company f �� <br /> Print Name Gv��l is�-- bJ� I J(/ i Date �G /d-l— oy— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> l <br /> Application Accepted By (,��rn-��� Date Issued dl Area <br /> GFinal Inspection By Date <br /> Grout Inspection By Date <br /> Destruction Inspection By Date <br /> 'OMMENTS/CONDITIONS: 0 <br /> ;OUNTING ONLY: AID# <br /> DES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> AX 141 5 Ak- - /- 60" t-IS <br /> 'NC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />