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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, <br /> � EnvironmenlHeallthDivision.� <br /> ip /S Parcel#U �'/X- <br /> G <br /> WELL location U1� )� L Cross Street,'j City4Z <br /> 11 rr lll l Zip Psai Phone# q3I -,L-E <br /> PROPERTY Owner aJ�neS-1'�1 G N/I C'CGvlAddress yUC7 F w�l�' Citty S� <br /> C-57 Contractorc^r•^aoo llf 11( til, Address 3$7 J- Orme Cird-e CityCOr ON� ZIp9 Lic#�IxloPhone#�9/6) �(� <br /> Consultant/Sub ContractorAC14� Address g Z? G h,iN QpD, Cjty5� Uc#—Phone# x/67 6- <br /> Y ,Township Range Section <br /> GIS Coordinates:X - <br /> RK TO BE PERFORMED: p DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) 0 OVER-BORE <br /> ,SOIL BORING# i 1 Im�C 0 PRESSURE GROUT <br /> O WELL# <br /> Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLEMULTIPLE CASINGS?]]YES O WELL CASING DIA: J <br /> S�¢ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS n✓� _TYPE OF CASING: 0 STEEL IIPVC OOT ER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Fn�2 re, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: X'es p�NIo (NOTE: pMA11X''IMtQI M FREE-FALL DEPTH IS 30') <br /> SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: `1H I I7 Ak4 Po�'ria✓d" '1- (2 C I/Ong WG�(',✓- <br /> \p OTHER:—0 <br /> OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> -rI0' 0 <br /> (if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSEDYVA <br /> \COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4o 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 Ord' ances, Rules pnd Regulations, and all applicable California State Laws. <br /> ��jL,,, �-- Title/Company <br /> Signed x_\ C _� <br /> nn // Date �"5 �-0 <br /> Print Name gf- M I Ili �° ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: a Tietz I <br /> ate Issued 00I Area <br /> l <br /> n Accepted Byinal Inspection By Datepection to Dateon Inspection Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE �� PERMIT I SERVICE REQUEST# INVOICE <br /> v� DO 15 Z <br /> C-57_ WC_—WAIVER_ C-57 Letter of Auth ri ti n 0 Sign permit_Encroachment doc_. 9/27/(' <br />