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' WELL PERMIT APPLICATION FORM <br /> SITE <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESMITIGATION <br /> . 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 apphc�Gon is made in compliance with San <br /> Joaquin County evetap�e Title,Ch pt r 9-1115 3 and the Standards of San Joaquin County Public Health Services I n nronmental Health Division <br /> q ry ort Of SIS IC Rd. 6 <br /> Assessor <br /> WELL LocationCross Street r Rd. &J Stockton Zip ` 3 Parcel# 3145-03-01 <br /> PROPERTY Owner Port of Stockton Address city.- ZIP POB 20$9 Stockton 953Phone# <br /> 01 209-946-0246 <br /> C-57 Contractor Fisch Address 399 Sher. -S Pl. C,tyValley SRgS. Lic#6 865Phonet?09-772-3570 <br /> Consultant!$i]{»3K2= Geomatrix Consultai 2444 Main St. Ste. 215 �'Z�S <br /> ss City ErjPsndL1c# Phone# 559-264-2535 <br /> GIS Coordinates X Y Township 1 N Range 6 E Section n/a <br /> WORK TO BE PERFORMED <br />'7ELNEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HANO-AUGER OTHER-) Q DESTRUCTION(choose type below) <br /> 3&SOIL BORING# — 11 OVER-BORE <br /> WELL# FS U� 111 <br /> 'Other 4 direct U5 soil rzn S Grout Specifications Neat cement grout fPOt C�OCC�[Ii ?j T <br />' COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />' 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS-) 0 YES []NO WELL CASING DIA. <br /> 0 EXTRACTION [1 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL a PVC []OTHER <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED U AUGERS 0 HOSE <br /> I#RSPARGE Xg PUSH POINT GROUT SEAL PUMPED 0 Yes U No (NOTE MAXIM UM FREE-FALL DEPTH IS 30') <br /> L BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or <br /> (]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES list specifications here) <br />' -COMMENTS 2" diameter direct push borings backfilled wittF�cement/grout when completed <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 to accordance with San Joaquin <br />' County Ordinances, Rules Regulations, and at] applicable California State Laws) <br /> Signed x r , St I—tle/Company rmf ec C��a��dc}�i <br />' <br /> Print Nam Date12=.1 J�7[o` <br /> DEPARTMENT USE ONLY <br />' SITE MAP IN UNIT IV FILE, ADDRESS 113 �I 4 <br /> WORK PLAN DATED' {{ L' <br /> Application Accepted By Date Issueda <br /> _ G1 L AreGrout Inspection By i Date Final Inspection By Date <br /> — <br /> 1 <br /> Destruction Inspection By Date <br />' COMMENTS 1 CONDITIONS <br /> COUNTING ONLY A109 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST It =INVOICE <br /> .� ��s <br /> IC-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 9/27/00 <br />