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APPLICATION FORM SITE <br /> WELL PERMIT A _ <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> SPP - 4 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ;;. <br /> �,• r i ;. 209 468-3449 <br /> P -J <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 Divis*on. <br /> Assessor, <br /> WELL <br /> s,R, Lds <br /> WELL Locatlon 5/i! i� Cross Street :City �t'' ' Zip_Parcel (1r <br /> PROPERTY Owner (f a�fyu//S Address ?V70 ?3�62 City 1 �/7 Zip jy,z3Phone#: .. <br /> Su/7 <br /> C-57 Contractor lz fal?ek Address r e City2�•Zip�1�ys 1T_Lic#��Phone G� <br /> Consultant/Sub Contractor '0 G Address z3s�li'�ejeq6LIL !'City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, EOPROB HYDRRRPUNCH, ND-AUGER.OTHER') 0 DESTRUCTION(choose type below) <br /> �S BO lNG# G/ Gi OVER-BORE <br /> Q 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 z-,/xL,MULTIPLE CASINGS?0 YES a NO WELL CASING DIA" <br /> p EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL p PVC I]OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> 0 AIR SPARGE %.PUSH POINT GROUT SEAL PUMPED: d Yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> G OTHER:_0 OTHER APPROX.BORING DEPTH ��7 ed'o BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? if YES,list specifications here): <br /> 01 <br /> 'COMMENTS: --V,,71 <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 is pplication and that the work will be done in accordance with San Joaquin <br /> County Ord' es Rule an kat• ns, and all applicable California <br /> State Laws. �I Y <br /> Signed x i` �' Title/Company(7 0060-/ G� ��ri �/� <br /> c_ _aPrint Name 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 I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE I <br /> 290/ <br /> 139 y /P�f7 -e—e5' J3 6 <br /> f <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />