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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> -ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ZO0j <br /> (209) 468-3449 <br /> SEP <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEPL• E COPY <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 l�'/,�pIwinent Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> '`1��X01ILD, Z� arcel#0g2'Zod —G(c <br /> WELL Locations 99 'j p r!', Cros1ss StreetCAI%1L��-1 City Zip <br /> PROPERTY Owner Hwa- :rfa& - bxl(� Addressf D• � / c� ! City. IC(-LLZ"t cw <br /> Zip�Phone# --32C <br /> C-57 Contractor MtT04itJ-7D VAW��r Address�6 Sca-rg MIA-r-fAyE Chi` • ' i�N6 Zip.�2& Lic# 7 /l Phone#�/gllo01- <br /> U�r.I S� <br /> Consultant/Sub Contractorpbo &ii;rwkI l?'. Address x•37 S�I�AulJ t��%�� CityS J�ld� Lic#4'"Z Z� Phone# t�'/�/by <br /> GIs Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> jI SOIL BORING# 0 OVER-BORE <br /> WELL# �� PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 9 MULTIPLE CASINGS?0 YES VNO WELL CASING DIA: t <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS D CZE' TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL r()li4L /]'7L/ TREMIE TYPE TO BE USED: AUGERS HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH_-7o XBOLT D TRAFFIC BOX or 0 STOVE PIPE <br /> �1 p� CONDUCTOR CASING PROPOSED?�_(if YES,list specifications here): <br /> *COMMENTS: I �'`�'ill7 1 )AIE� �lAtnI( 7dQ(�{.r UEG�S l/(�S luw�l� -7i -71) ' r LdL� 5JV-Fk- <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 repar d this application and that the work will be done in accordance with San Joaquin <br /> County @r�Tc Prr c s Rtlles an( a ulations, and all applicable California State Laws. /A <br /> Signed x JJ Title/Company �l�C' `'I Backs T <br /> Print Namet.�L L� L^ I Date ! d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> G0Z7 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />