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�.I <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> F 7 20C§AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> S`P 2 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> E. Weber, Third Floor, Stockton, CA., 95202 ORIGINAL <br /> (209) 468-3449 <br /> NON-REFUNDABLE PER <br /> MIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> Development or al This <br /> ,EnI �with <br /> San <br /> cattionishereby <br /> made <br /> tSan <br /> Joaqun1for a permit to Public Health Health Division. <br /> Joaquin ir&15.3 and the Standards of Sao Joaquin County Services, l <br /> .Assessors i <br /> y Zip 30 Parcel# <br /> WELL Location (S 66 S -7,,1f tl 51A� A.X--Cross Street_�� _pity "�J <br /> PROPERTY Owner yln�"Ion ,�ttn .t'tr1�--Address_ m `r �� Ci1ty�Fd "r-�--Zip�1SL2-Phone# <br /> nn ������ u z�-,Cf M:.r..l s�l('j City iy�t�yrec"-lp Ig &Qf tjc# 0 2 Phane#�OU-y2�'�/4i3 <br /> C-57 Contractor -4i;�^_P Address <br /> -"k <br /> A 1 Q�-> , 1 Cjty Q� Lic#bR0 ?� Phone#Za9 7-�O�b <br /> Consultant/Sub Contractor l to [nm k �f .,,:,.,,..��Ad r ss-Fi]-L�.+v . <br /> iRange Section <br /> GIS Coordinates:X ,Y.,Township <br /> WORK TO BE PERFORMED: a DESTRUCTION(choose type below) <br /> �IEW W ELL I BRING( <br /> OCP C O ,HYDROPUNCH.HAND-AUGER,OTHER`) (I OVER-BORE <br /> a SOIL BORING# 0 PRESSURE GROUT <br /> SWELL# Grout Specifications: <br /> 'Other. i <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?U YES 'kNO WELL CASING DIA: _ <br /> o EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS­LF TYPE OF CASING: STEEL PVC OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL l .Y �a�rFN.. TREMIE TYPE TO BE USED: O AUGERS —&HOSE <br /> n AIR SPARGE I;KPUSH POINT GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREE-FALL DEPTH 13 30') <br /> RSOIL BORING :40 HAND AUGER - GROUT SPECIFICATIONS: �C* OC ED TRAFFIC BOX or Q STOVEPIPE <br /> o OTHER: ()OTHER APPROX.BORING DEPTH / D <br /> n CONDUCTOR CASIN(G' 11PRO1P1OSED? (if YES <br /> 'COMMENTS: ,list specifications here): <br /> � �� ,Y. ��� ��---1� <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 Ordipancces, Iles and Regulations,and all applicable Californian State Laws. <br /> Signed x ((\\JJ 1111.. Title/Company 1"W Date <br /> �r <br /> Print Name a>J J P <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 15615 7 " <br /> WORK PLAN DATED• 1'� <br /> Date Issued Area <br /> Application Accepted By,, yg!� efl7 <br /> Grout Inspection By <br /> Date - Final Inspection By `'t l C__Date ! '2.4 •0 2-. <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> EPECODES <br /> TING ONLY'.' AID# <br /> FEE INFO AMOUNT REMrrTED CHECK# R 'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> W <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_. 9/27/00 <br /> t <br />