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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 Assessor's <br /> WELL Location [9 0uc�bA fi Cross Street k?R jeAjj.In Lpnr City �n�_I Zip�/Sa �—Parcel# �/ <br /> PROPERTY Owner Address))o r<PcAL j woes Qky City RP txod6`� Zip9,OS Phone# ( `C �}1�?� <br /> C-57 Contractor8��{i�U'��c�✓/](Yt31Q'Address Y„7 5 Vx���Y� CityS O✓� Zip �06 <br /> - <br /> Consultant/Sub Contractor !�6ME uS 'A�OVC Address City Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Wq EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> ,'{SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE <br /> �x MULTIPLE CASINGS?[]YES []NO WELL CASING DIA: <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL F-04,C'q- TREMIE TYPE TO BE USED: 0 AUGERS <br /> 0 AIR SPARGE jf,PUSH POINT GROUT SEAL PUMPED: 0 Yes RNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH D <br /> 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 Ordi nces, Rules an egulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name II 1 I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 2 y� <br /> �(� I Date Issued O � Area s" " <br /> Application Accepted By— T <br /> Grout Inspection By Date Final Inspection By Date _ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 71 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S R# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />