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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 JUL 2 3 2002 <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 Develop en 'tl ,Chapter 9-1,115 an St dards of San Joaquin County Public Health Services,EE'I� 6"TRfdNAk -i <br /> �, sroar<eD ; p �} <br /> WELL Location Poir�� Sm�XJZrV Dl�T1k �C T Cross Street n��vy D��r= City S1LC�'fC� Zip Sq Z6& Pa'&* <br /> E�3�`o9 <br /> 7 <br /> PROPERTYOwner STr� ` emoi>` Address 2101 W • WAS1ill4cm-S acity SiOCIcTCN ZiPhone# '1_tlq" C1% bZyb <br /> `I <br /> C-57 Contractor W �AZMA T Address ���3 F�FTi6"AL)) 1Loi City2ANtltt Zip95�`1Z Lic#59197 Phone# 63342�� <br /> co;Zpa.9"IA 2'qjVC0z <br /> Consultant/Sub Contractor SECOIZ Srj—.MQA?0kn LAddress 0-1 ICILGIPE Jed Citycoavh Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: PleA5c' Sea /IrMcgrD F,oawrs 4i5r1)r6,c:,euS Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,'MONITORING gHOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> EXTRACTION FAIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> gAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: 4F LE S SEE 7t�1Gn GaR snAi u62L - S <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 certif that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a ces, 1 and Regulations, and all applicable California State Laws. <br /> Signed x — / <br /> Title/Company �c't3� —TrrTE�ti'�' 7nW''►� ��� <br /> Print Name IVODate �%/2 7 <br /> DEPARTMENT USE ONLY ''TT <br /> SITE MAP IN UNIT IV FILE,ADD ESS: <br /> WORK PLAN DATED: O C(,IR!ti <br /> Date Issued (o OZ Area, <br /> Application Accepted By <br /> „�- ",- br <br /> Date Final Inspection By Date__ <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING ONLY: AID#E CODES FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -qa� &s l.�l� 8 oz OD3o7�3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br />