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• 0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQI;IN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD}- c <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 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 � �� . ty p Assessors Z <br /> ross Street Cit G� ZiG(P Parcel# <br /> WELL Location C <br /> PROPERTY Owner+7)?C ��V L' �� � Address 'J+4 C' City " [? Zip r� Phone# 5%I—42-LiI <br /> C-57 Contractor SPyCjT�' � Address 2-3(.6-e-JIW��- ,..wa, City S4-Li­ Zip !s&'� Lic# (22Z47Phone# <br /> /W <br /> Consultant/Sub Contractor[�Lu�'c1-u4c e e �-)L Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 5i4EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# n OVER-BORE <br /> ELL# 0PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING (]HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?0 YES �10 WELL CASING DIA: Z <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS e, , Lt Q TYPE OF CASING: 0 STEEL []PVC H OTHER: <br /> H VAPOR []MUD ROTARY DEPTH OF GROUT SEAL I(oS * TREMIE TYPE TO BE USED: O AUGERS HOSE <br /> []AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 4 <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �3 eJ- <br /> (]OTHER: []OTHER APPROX.BORING DEPTH -Z 2,0 ` 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?V_(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 hereb 'fy that I have prepared this application and that the work will be done in accordance with San Jain <br /> Cou y Ordin nces, Rul s nd a la ions, and all applicable California State Laws. sonam <br /> r Title/Company <br /> S� cy!!^ <br /> Signed x <br /> Print NameI lam,Vt elLx^� Date <br /> DEPARTMENT USE ONLY C003 <br /> SITE MAP IN UNIT- FILE,ADDRESS: CLI <br /> WORK PLAN DATED: C <br /> Application Accepted By C Date Issued 2- / S 6 Area <br /> \ <br /> Grout Inspection By Date 2- z3 C Final Inspection By Date 2 z <br /> �,;'l-+��nnc1�. <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 /> 2 rs of ' G> 5-Z � <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />