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- WELL PERMIT APPLICATION rJkiVI SITE <br /> '- - MITIGATION <br /> G� 0 6 Z iJ 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 /> 11 (I Assessors <br /> WELL Location l Z ZS C 1�1 CI Akl n Z�n Cross Street 'Z City Zip 9�r�Z,I Parcel#Op (��(� - <br /> PROPERTY Owner�y�� ��� CLt%fC�' Address l((1 n'5 C �ll City St tJ��,^^ ZiN� ��LPhone# I Q��O-�07�� <br /> C-57Contractor 6(ec- Address 'B37 �7Ui�1 UL �Lic#Phone# (40- ICOG <br /> Consultant/Sub Contractor Z nV1 r pet 6-Q Address City Lic# Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED:)IrDESTRUCTION (choose type below) <br /> NEW WELL/BORING(CP EO .R01 E,HYDR9PUNCH,HAND-AUGER,OTHER-) OVER-BORE <br /> RSOIL BORING# � ( P-Z 1 P-3 0 PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> •�MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE--?� MULTIPLE CASINGS?DYES WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /1 TYPE OF CASING: 0 STEEL 0 PVC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL `Cc'ka 4,,( REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 AIR SPARGE -JZPUSH POINT GROUT SEAL PUMPED: a Yes <br /> J(SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH L 0 (j 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 /> hereby certify that I hve prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi Res es and Regulations, and all applicable California State Laws. —ate <br /> r3I ��-C <br /> Signed x Title/Company vii;moi �`7� ^ <br /> Print Name DO <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 1 /� <br /> Date Issued Area <br /> Application Accepted By <br /> -' <br /> Grout Inspection By <br /> ate ob Final Inspection By Date <br /> Destruction Inspection By ate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ;59n <br /> 0/'% /01 C <br /> C-57 WC -WAIVER_*C-57 Letter of Autho iz io o permit_Encroachment doc 9/27/00 <br />