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S <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <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 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 /> WELL Location 151%uI P_6')P_6') Cross Street City Esct lo� Z;p 953Assessors <br /> zo Assessor's <br /> PROPERTY Owner q c,,,� �tdWT 'va Address(s634 Si-uM9�I c;ty Es colas Zip`f3'y2' Phone# 838-7,V94 <br /> C-57 Contractor GT;Lqq T"4,fy ,1 1Address '60 flowC 7�4 Cily_tj1 ,,CZ Zip 9f553 Lick 454f07 Phone#V-313.57(2 <br /> Consultant/Sub Contractor ATC A r-c-,,TCS Address (((9-'$ L6tiP P<Im Av,- City Maolc4lo Lic# Phone# 209-577-2221 <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORME <br /> NEW WELL!BORING( PT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type bel ) <br /> SOIL BORING# CFT1, CPT Z, . CP73 0 OVER-BORE <br /> 0 W ELL# 0 PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: BOTHER APPROX.BORING DEPTH 1501 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 Joaquin <br /> County Ordina es Rulles a�nd- R—egu�lations, and all applicable California State/Laws. /)- <br /> Signedx'=L! f�. ' Q� Title/Company Jvh' (5 oa t /,4-/-L- <br /> Print <br /> ,4/C fiSSOCi s�tJ <br /> Print Name ,w, K''�J G("—F_ —Date i'2-0'ZW/`h <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: „ (( f� <br /> Application Accepted By Date Issued IwA T 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 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 Letter of Author. ion o sign permit_Encroachment do(:__ 9/27/00 <br />