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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 <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,Ch ter�9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 1316C)O 4 : Iravwv�[a.ot by StwKislo.r.s� Assessors 1� ! <br /> WELL LocationCb►whhal�C�r4y'y + l/JA.60-r Cross Street City 'Sive-k.iVn Zip Parcel# 30A 0.7j-AG��JI <br /> PROPERTY Owner SLt- 00.if06,L1►aJ Address City Zip Phone# <br /> -rSo." *OS <br /> C-57 Contractor MY-ov%iL C LY1C.. Address 2110 A410.1wb Av@.. CityLaw-�ro Zip,`57j1-ic# 9LI Phone#510-$!r$-4(*% <br /> Cer► or dkv*Tk 188 Fr••^k- W&st <br /> Consultant/Sub Contractor i ate Address Cir. Stt. I City�'ocLC+On Lic# Phone#�.*'1-Z3�-OS/8 <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 /> G SOIL BORING# 0 OVER-BORE <br /> o WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE 26" MULTIPLE CASINGS?a YES R/NO WELL CASING DIA: <br /> B EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL o PVC o OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 14A TREMIE TYPE TO BE USED: D AUGERS WHOSE <br /> o AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: hes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> eSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: `t <br /> G OTHER: - THERDirt&' Pwsl* APPROX.BORING DEPTH$" aN'ae. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> 'COMMENTS: Ptio►Sm `�,+. ev%,ji '0r1YNLN}A1 si'f't- Nes, -stme-nt: I��la�ra►u�ic.i o(.IYac-F DbtSh <br /> ri r fizil a.Kd rawKdwat&v- sn <br /> NOTE: OFFSITE ORINGS 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 Regulations, nd all applicable California State Laws. <br /> Signed x ?7( T� Title/Company E r1 V S Q Y'V. Myr- C <br /> Print Name Dav W 00 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> F.d 1� Date Issued <br /> Application Accepted By �— <br /> Grout Inspection By Date Final Inspection By <br /> 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 /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />