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I <br /> WELL PERMIT APPLICATION_ FORM SITE <br /> t f i MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 W���u� D <br /> (209) 468-3449 W u <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB 0 5 2002 <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 Service a ion. } <br /> t7i�f isV <br /> I <br /> WELL LocatlonR P'lly Arccia, Cross 1114, 5. (:b" <br /> city t? �1..� ziF ITr�� <br /> �FRM �ICES <br /> PROPERTY Owner ( x� ./a..�, Address`1114, 5. TL'1y_','kzipj4f64- <br /> Zip�q ZA�Phon e#_�(..1jj w--L3 <br /> C-ST Contractorfeci�..n ol.� Address 140o S. SOIL �rn+ tiLIC#Lj62aPhone#Sr<o,Z3�.4S-l� <br /> Consultant/Sub Contractor.(T C­'x(I22tJ'o,n Address 1'24 IU.filxrttt+ Wit_,_( City�Llc# Phone#_111Ti,f 4i 3 <br /> j <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORME <br /> NEW WELLI BORING CP ,GEOPROBi=,HYDROPUiVCH,NAND-AUGER,OTHER") p DESTRUCTION(choose type below) <br /> []SOIL BORING# p OVER-BORE <br /> 0 WELL# n PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING []HOLLOW STEM DIA.OF BOREHOLE 2 %per MULTIPLE CASINGS?0 YES /NO WELL CASING DIA: <br /> []EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS norle TYPE OF CASING: []STEEL []PVC []OTHER: <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL I O> �4- TREMIE TYPE TO BE USED: []AUGERS j HOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes ■No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: of 0 <br /> 1]OTHER: fl OTHER APPROX.BORING DEPTH_1 C�o BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_ !'l 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 I have prepared this application and that the work will be done in accordance with San Jo 10 <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x /tom ;,61:124640., Title/Company e IT <br /> Print Name A Date 'Z OAt <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: L - <br /> WORK PLAN DATED: 1--c <br /> Application Accepted By G+� Date Issued "+-I <br /> a O Z ._Area <br /> h 6-An <br /> Grout Inspection BY Date 'Z- 5 Final Inspection By 3 Date <br /> P <br /> i <br /> Destruction Inspection Ba Date <br /> COMMENTS I CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID## FACU <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3s01 •a o Z ( az %goS <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit 'Encroachment doc 9/27/00 <br />