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WELL-PERMIT APPLICATION FORM SITE <br /> SAN JO Q IN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> �d�� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 Health Division. <br /> ` f { Assessor's <br /> WELL Location �� LI N�U 9G! Cross StreetCi_ArzKSDA(IGity LCj { zip!b 2qn Parcel# <br /> PROPERTY Owner 1D&E= i (L /dress&31 i-, Lcc-�Foap 5 City 7ip���QPhone#2,01A 33 /I I <br /> C-57 Contractor r-U iyI Address 2 3Q7 W16WA� City ` kip Lic#�/Phone# Z. <br /> Consultant lSub Contractor ILL &r dress /77� �ADOK K;�iCity �.bV Lick1j7 � Phone# 3i! ia�`73�i'� <br /> GIS Coordinates:X Y Township Range Section <br /> WOSK TO BE PERFORMED: <br /> EW WELL 1 BORING(CPT, GEOPROSE, HYDROPUN�H,HAND-AUGER,OTHER") Q DESTRUCTION(choose type below) <br /> Q SOIL BORING#W I� 2 _ Q OVER-BORE <br /> Q WELL# u I Q PRESSURE GROUT <br /> 'Other: Grout Specifications:_ A 1 lir J cV__d;_ <br /> COMMENTS: <br /> TYPE-16F WELL INS TION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONtTORING OLLOW STEM DIA.OF BOREHOLE `� MULTIPLE CASINGS?Q YES 040 WELL CASING DIA: Z ya <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL VC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS OSE <br /> p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: 0i5ntdr,v`7_+ �V t �� <br /> Q OTHER:_a OTHER APPROX.BORING DEPTH Lav OLTED TRAFFIC BOX or []STOVEPIPE <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 h e pepare t is application and that the work will be done in accordance with San Joaquin <br /> County Or ' nceS ule nd Reg ations, and all applicable CaliforniapState Laws. <br /> Signed x TitlelCompany C i iVr LG <br /> Print Name !r��! 1 �=1f 1 rJ Date ` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: t ILL but- I' /� I/ <br /> Application Accepted By1�-�` Date Issued S Gf' Area <br /> Grout Inspection By Date 15It p/ Final Inspection By Date It C" <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: W <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D DATE PERMIT/SERVICE REQUEST# INVOICE <br /> BY <br />� I 1 5-SDI � - <br /> C-57 WG -WAIVER C-57 Letter of Authorization to sign permit Encroachment do,__ 9/27/00 <br />