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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 /> 344 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaqusn 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 /> Assessor's <br /> �} LJ-1 S�-� �' l�yGG <br /> WELL Location 'Z � A.r Fir L-)' Crass Street ��- Cin' _ZIP 95 Parcel# �+o�nn ✓-�-�� <br /> PROPERTY Owner `c�-- Address City Zip Phone# <br /> r -� Cityl'7- �*•2 Zip 9_ ��53 Lie# Phone <br /> 9-7-5-3/J7'���, <br /> C-57 Contractor G'� i,!(, Address ar-d <br /> �! <br /> ConsultantISubContractor Ste, y�� (Address �`f r✓' f2,��c CityDi�1�Lic# Phone# $.25-F� 93 g/ <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED []DESTRUCTION (choose type below) <br /> ErNEW WELL I BORING CP GEOPROBE HYDROPUNCH HAND AUGER OTHER-) [)OVER-BORE <br /> .SOIL BORING# L 0 PRESSURE GROUT <br /> ❑WELL# <br /> 'Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0MONITORING 17 HOLLOW STEM DIA OF BOREHOLE �/,, MULTIPLE CASINGS?Q YES ONO WELL CASING DIA / �! <br /> (I EXTRACTION 17 AIR HAMMER/DRIVEN CASING THICKNESS / TYPE OF CASING O STEEL d PVC 0 OTHER <br /> ©VAPOR MUD ROTARY DEPTH OF GROUT SEAL%cra l _� '--TREMIE TYPE TO BE USED 9:AII ©HOSE <br /> Baas p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SPARGE BUSH POINT GROUT SEAL PUhSPED <br /> *01L.BORING Il <br /> HAND AUGER GROUT SPECIFICATIONS /at <br /> 0 OTHER n OTHER APPROX BORING DEPTH /y0 0 BOLTED TRAFFIC BOX or 17 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /IIA (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 l have prepared this application and that the work will be done to accordance with San Joaquin <br /> County Or c les an egulations, and all applicable California State Laws, <br /> TillelCompany 4�4 <br /> Signed x j <br /> l �lgG�r Date 1_ <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRIIESS — �`-- <br /> WORK PLAN DATED: I1 `� t <br /> (� �� � <br /> Application Accepted By 1_�e� — � Date Issued Area Date <br /> Grout Inspection By G�- ` >��1 r� Date Final inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> CCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> x111 , 1 ���,.. - Ia3/� DDS _5k3 <br /> t 9/27/00 <br /> C-57 WC -WAIVER? C-57 letter of Authorization to sign permit Encroachment doc <br />