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SOW r. <br /> WELL PERMIT APPLICATION FORM 1$ITff <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH bIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is rade in compliance with Sar <br /> .oaquin County Development Title,Chapter 5-1116.3 and the Standards of San Joaquin County Puolc Hearth SenAces.Envlror rental Healh Division. <br /> Assessor's <br /> WELL Locatlon_I 044 S• tW� rJSO+ W�Cross SS,tree(t�. r& City SWI L4 P__Pareel# <br /> PROPERTY Owner 1 bu CDe.`C Address J:Lo m 'L tt .3� Cjly Zp Phcne#j4bU- �r3cI 41 <br /> C-57 Contracter!sq"�'. Address7tL$ )6&jjj XM JX Clty t .yy�Lp_��OSUc#�j P^.one#Q -8-112. <br /> 9T— / � p�"" <br /> Conaultant I Sub Contractor(1 f mel ZGrV Address I'IILI lrw �'(- Gt�( jfa+ Uc# Phone#2oS 838-9 <br /> GISCoore(nates:X_ ., ,Y_,Township Range Sector <br /> WORK TO BE PERFORMED <br /> ."!WELL!ECRItIC(CP-,GEOPROBE,HYL,POPU>!CH.HAND-AUGER,OTHER ) p DESTRUCT10%(choose type below) <br /> [)SOIL BORING# D OVER-BCRE <br /> WELL# IM W IG� I 0 PRESSURE GROUT <br /> 'Other. Grout Specifications: //A-J 5! a,,4-- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XONiTCRING OLLCW STEM DIA.OF BOREHOLE R„ MULTIPLE CAS.NGS? D YES zKb VIELL CASING DtA:,� <br /> D EXTRACTION D AIR HANIMER'DRIVEN CASING THICKNES33CJs 40 TYPE OF CASING D STEEL W VC []OT HER: <br /> D VAPOR 1]MUD ROTARY DEPTH OF GROJT SEAL TREMIE 7YDE TO BE USED, GAUGERS VROSE <br /> 0AIR SPARGE D PUSH POINT GROUT SEALPUVPED:-RYes D No INOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: AIpG4 e4m R,F $CL n1 <br /> Q OTI-.ER: r!OTHER AaPRCX.BORING DEPTH SCLTEC TRAFFIC BOX or D STOP_PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,lis;spec:firations 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 certity that I have r pared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' antes ules d Regulations, and all applicable CaliforniiaCa State/ Laws. yy <br /> Signed x _ TIte/Ccmpany , ax/ <br /> Print Name �YR1A1CUZL1 ((-- Date �Gb <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: (,k), `��� (4),9-(j S-fZ c �� <br /> WORK PLAN DATED:_ 1AIC, 1 <br /> Application Accepted By Y r11 ��iG'�L`'� Dale Issued !S G Area y <br /> Grout Inspection By Date _Final Inspection By L7ylt Data 3-7 LS <br /> Destn,ction:rspecticn By Date <br /> COMMENTS ICON DITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECKS RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35aI -" Ic5 _? � <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroochment doc_ 9/27/00 <br />