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' K <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 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 <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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> BIOGk 3: bo&4&%A.A b y A %V-0 rw' Assessor's <br /> WELL Location (�lirtl.r V POLIL, + C.1�e.Ky%,&1 Cross Street City Stile— -i-pr► Zip Parcel# 341A A.1j7�.c.�tn <br /> PROPERTY Owner St.f- M*06c.40-01 Address CityZip Phone# <br /> $*A-% *OS <br /> C-57 Contractor Virov%Q.Y. 7-n(-• Address 2.110 A410.my /eve. City l.sw►•o�wo Zip 1'�S�tic# qty Phone#510-$b$-41e� <br /> Cev► or wrtk /88 i=r•N%A_ West <br /> Consultant/Sub Contractor Te-cknol ogies.=N4Address C;W-0 Stt. I City:{"oc +6r1 Lic# Phone#,40i'Z3-4-Osla <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW 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: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2.s' MULTIPLE CASINGS?o YES R/NO WELL CASING DIA: <br /> H EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: O STEEL O PVC O OTHER: <br /> I7 VAPOR H MUD ROTARY DEPTH OF GROUT SEAL 14h TREMIE TYPE TO BE USED: Il AUGERS V HOSE <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: ees p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: THER Dirb,.t P"!66 APPROX.BORING DEPTH i" o►#o e. p BOLTED TRAFFIC BOX or []STOVE PIPE <br /> �} CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> 'COMMENTS: ev%vieoy ty%aN}o►1 S i'l*- Ae s."t a-n-1': <br /> looviv%wsr isoil ould ray%r.al wat'.r a W% <br /> NOTE: OFFSITE ErORINGS 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances`, Rules and 7;=TitlelCompanveviv. Date <br /> able California State Laws. I <br /> Signed x 77[ le, e_rv- gZ <br /> PrintName LJ0.VIr� F. WOa� �� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: I� � � QQ� <br /> Application Accepted By /�'!\�' "`'` Date Issued� 0 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �D <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />