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• FORM <br /> WELL PERMIT APPLICATIONSITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Stockton, CA., 9520 <br /> FILE <br /> 304 E. Weber, Third Floor, <br /> n ECOPY <br /> r 1 <br /> (209) 468-3449 <br /> Sr 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 I �apment title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ,,// ,�11 _ Assessor's <br /> WELL Location-) `�nL 114/l! /{ry, Cross Stree�t��f{� 0�0_✓- �1 City'((> � Zip Z� Parcel# 0�2-ZB� �()(; <br /> PROPERTY Owner &Y- �Ej&V_ Lt f.CS Address�D_L `Zc O-� 1 City 5 I CCk&Lj Zip&'9Phone# © <br /> C-57 Contractor MIT'(AC t.�W idr Address�ea -'.a-rq VA-rT Aa_ Cit4/�P�tNF�[7n Zip�'Z�y Lic# 7�I7 Phone#r,�//lly��'3�- Sa <br /> Consultant/Sub Contractorpb&uo ddress�'3l SI Aiv g5A> City. Lic#&CtZ27Phone# <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 /> SOIL BORING# 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE r MULTIPLE CASINGS?0 YES �f NO WELL CASING DIA: 21 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS G CZo r� TYPE OF CASING: 0 STEEL xPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL r,)7r4r_ t]� TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: x Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH) )(BOLT6D TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 1l o (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 Ihave repar d this application and that the work will be done in accordance with San Joaquin <br /> County �3irt c les an` R ulations, and all applicable California State Laws. / <br /> Signed x / Title/Company �i—,a "-k tekS 7 <br /> Print NameAI,tL Ll'.LrG.^ I Date ? <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 /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />