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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 I YEAR FROM DATE ISSUED <br /> pplication is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compiiance with San <br /> oaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Dwision <br /> � � Zi 95 3 3 Parcel# <br />`TELL Location I ,r �� L-1 Cross Street G1 �031��}✓- Ctty � p <br /> IROPERTY Owner �S Address 7I r �lJ— �� Cary n ty�� Zip PhoneJ'�� - o / <br /> � <br /> 9�5 -3/3 -5y`° <br /> -57 Contractor­_( ,- t1,, Address_ 55 2 �" - `� Ciry "fi"' z`p 9. ys��-L�c# Phone <br />;onsultant!Sub Contractor <br /> rSAddress 7*32'+- P"j-'j'2 Cjry?E`^✓ //r Lic# Phone# <br /> 31S Coordinates X Y <br /> Township Range Section <br /> WORK TO BE PERFORMEDI] DESTRUCTION (choose type below) <br /> Oj NEW WELL!BORING PT GEOPROBE HYDROPUNCH H LyAUGER OTHER') 0 OVER-BORE <br /> �SOIL BORING# 70 PRESSURE GROUT <br /> []WELL# <br /> Grout Specifications <br />'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NO WELL CASING DIA <br /> 0 MONITORING 1)HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS'11 YES 4 <br /> []EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS <br /> ��TYPE OF CASING I]STEEL O PVC O OTHER <br /> TO BE USED [AUGERS HOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1��/ 2 TREMIE TYPE � <br /> SPARGE VPUSH POINT GROUT SEAL PUMPED A}Yes ONO (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 101L BORING IJ HAND AUGER GROUT SPECIFICATIONSo BOLTED TRAFFIC BOX or a STOVE PIPE <br /> o OTHER ❑OTHER APPROX BORING DEPTH / -/ - Il <br /> CONDUCTOR CASING PROPOSED? {if YES list specifications here) <br /> COMMENTS <br /> NOTE, OFFSITE BORINGS REQUIRE ACCESS �RCENCROACHMENT ALL IRED iNSPI=c PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rul and Regulations, and all applicable California State Laws <br /> 110111 <br /> Title/Company 0 <br /> Signed 77 <br /> Date ,L �, <br /> Pnnt Name 11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS -- <br /> WORK PLAN DATED. 2- � � 1 <br /> `� Date Issued -2,Jr�7 J Area <br /> Application Accepted 8y Date <br /> Grout inspection By <br /> Date Final Inspection By <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS <br /> COUNTING ONLY A1D# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'i]BY DATE PERMrr I SERVICE VOICE <br /> REQUEST# IN <br /> 36r I `G, y -- "t(J) IL Cal 61 9/27/00 <br /> C-57 WC - AIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />