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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> C� SAN JOAQ <br /> UIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 wId5 <br /> (209) 468.3449 p• boy, 16 11 <br /> NON-REFUND BE PERMIT EXPIRES 1 YEAR FRODATE ISSUED STUALkbCR <br /> LM plication is made in I <br /> Applicat on is hereby made st San <br /> Joaquin <br /> lter 9 11ty5 3 nd the for a t to construct Standards oI$an/or JoaqLInUounlthe work ty Public Health Servlibed. This ces,,Environmental Health IDivissi Diance ivision. <br /> Joaquin <br /> th�n <br /> Joaquin County De elopm ' Assess is ^O <br /> }�� Z Parcel# <br /> r Cross Street <br /> City p <br /> WELL Locatlon3 Phone# I <br /> P � f LAS Address 0400 <. I l„f�n M1f1 City /CAp <br /> PROPERTY Owner ul Gil22 Phone# 1� /Z <br /> ��'—J—AddressCi Zip Li / / <br /> u M ,�1Ok.�uA ? �t`�l.lk�/ I1> 'x/62 7� �v <br /> C-57 ConUactor � ,/� o Li r3fl5k phpna# <br /> /�I � >. U— - Address -02-4 L- City <br /> Gonsultanc/Sub Contractory�,,d � Section <br /> Township Range <br /> GIS Coordinates:X •Y <br /> WOR TO BE PERFORMED: ESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER') Q OVER <br /> 0 SOIL BORING# "ESSURE GROUT <br /> 0 WELL# Grout Specfitions: <br /> "Other. z Z' "��l° - ' t Ion <br /> COMMENTS: `I� `6jC�' - Use t)Aka <br /> TYPE OF WE�� INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> RING 0 HOLLOW STEM DIA,OF BOREHOLE �4"MULTII'LE CASINGSGQ YES 10 WCLLO OTHER I � <br /> 0 <br /> MONITOR <br /> r}{ TYPE OF CASIN <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESSS <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA 5 TREMIE TYPE TO BE USED: Q AUGERS HOSE <br /> 0 AIR SPARGE b PUSH POINT GROUT SEAL PUMPED: es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> APPROX.BORING DEPTH W ❑BOLTED TRAFFIC 80X or a STOVE PIPE <br /> 0 <br /> OTHER:—U OTHER if YES,list specifications here)- <br /> CONDUCTOR CASING PROPOSEDo. ( <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS 'REQUIRE ACCESS �rICENoCROACHMENT R ALL REQUIRED NSoNs. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN AO <br /> I hereby c®rtify ehavepared this application and that the workt <br /> ill bdone in accordance with San Joaquin <br /> County Ordi ced Regulations, and all applicabl®Califore Laws. / / I <br /> Title/Company O/ / e �I C <br /> Signed x Date �I 17-7_L100 <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' Area f S� S <br /> Date Issued <br /> Application ACaePtedB Date��— <br /> Grout Inspection By <br /> Date � DU Final inspection By <br /> Destruction Inspectlan By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# <br /> REG'D 6Y DATE PERMfT/SERVICE REQUEST It INVOICE <br /> .oma- �0 - (,C>-(,C>- b (�L� tl z� ao Dai- X073 <br /> J-9. <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> Z0 �19dd �100-`IA HJ-UIU EEbE89760Z 65:EZ 0002;80/tl <br />