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IV <br /> r �F WELLUPERMIT APPLICATION FORM SITE <br /> REV, MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC-HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> OC (S ll��l 304 E. Weber, Third Floor,.Stockton, CA., 95202 <br /> - (209) 468-3449' h <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> i Assessor's <br /> ( <br /> WELL Location 203 R I. yL, Cross Street �A-`''�`F�, City S ""-`� Zip 9�"2b6Parcel# 7 , <br /> PROPERTY Owner �6 ji s`J u p 'e- Ci Ziip�y0 P[thone#,,,(-D-7g"T <br /> Wb !�( �iR ! � s� _City; i-o UI.D i -p C4 t .#����f�hone# 1 a7 �� ' <br /> C-57 Contractor O h�ddress ,�'�`7 r� ,/ <br /> Consultant/Sub Contractor � Address.-r] � 1 .A-ty�c# LPhone# .�u�' `f&7/00�o <br /> GIS Coordinates:X Y µ Township Range Section <br /> WOR TO BE PERFORMED: DESTRUCTION choose type below) <br /> W WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") D <br /> ©SOIL BORING# Q OVER-BORE <br /> []WELL# []PRESSURE GROUT <br /> :Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (n <br /> �ONITORING OLLOW STEM ;'DIA.OF BOREHOLE Z� 'fl MULTIPLE CASINGS?[]YES J WELL CA51NG DIA:�CI�� <br /> RACTION [I AIR HAMMERIDRIVEN 'l'CASING THICKNESS TYPE OF CASING: STEEL ��pVC OTHER: <br /> n VAPOR H MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: -ftCJGERS a HOSE <br /> a AIR SPARGE Q PUSH POINT F GROUT SEAL PUMPED:�]�'s '� No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS: ; <br /> 13 OTHER:_O OTHER APPROX.BORING DEPT ED TRAFFIC BOX or a STOVE PIPE <br /> CONDUC OR CASING PROPpOSED? (if YES,list seecificatlons here): <br /> •COMMENTS: <br /> ii III: <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 Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed xTitlelComparty <br /> Ip_S'-Zq <br /> Print Name <br /> iN 4' .. ' Date <br /> II: DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' Z> <br /> t <br /> Application Accepted By - l Date Issued D 'L C Area <br /> Grout Inspection By ;Date Final Inspection By to <br /> Destruction Inspection By DateS-O�-- <br /> COMMENTS 1 CONDITIONS: <br /> -ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED :° CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST If INVOICE <br /> r4-h LTD 15-77 d&7 We ! <br /> i C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />