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ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 /> / Assessor's !' <br /> WELL Location a 3/t7C' �C4sk c7 �,L1 Cross Street r City a Zip `/S 7 Parcel#� <br /> PROPERTY Owner (,.047 jle/vr>; Address d 3 Y -'"I-d l rk-r,'I t City 5 16,1 c o Zip`/s do j Phone# <br /> C-57 Contractor 6=r5;<<.,.1C Address 36fr 10.y1ZC L;-.lo CityZipqf-2-0 Lic#7/?3­10 Phone# 016)6$V 1169 <br /> Consultant/Sub Contractor Sf(191, -�7"P':lufro,,,;/Address 30/ 7 �, 1,11 c Fid City Lic# Phone#l''/d vypo <br /> i 40v,:, <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: \ <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AU ER,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BORING# A I a []OVER-BORE c <br /> ,WELL# AAA PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING r HOLLOW STEM DIA.OF BOREHOLE S MULTIPLE CASINGS?[]YES []NO WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS S`h'y� TYPE OF CASING: []STEEL []PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL f 5 TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: H Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: 1I/<'u Curr�n r <br /> i <br /> []OTHER: []OTHER APPROX.BORING DEPTH of' []BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSE ?�(if YES,list specifications here): <br /> 'COMMENTS: 04 002 <br /> NOTE: OFFSITE BO INGS REQUIRE ACCE 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, and all applicable California State Laws. <br /> Signed x- � Title/Company S-fr.-j:; /1f")eeT Scls.,Ir,S t <br /> Print Name r a` / `�_ �' / Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: -2-2. <br /> WORK PLAN DATED: .� <br /> Application Accepted By Date Issued /v/) <br /> im I Area q� <br /> Grout Inspection By Date Final Inspection B Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# Gerx <br /> PE CODES FEE INFOAMOUNT REMITTED CHECK# RE BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> MW 1QO 10 s # 00:Z02/ <br /> C-57 WC,/-WAIVER C-57 Letter of Authorization to sign permit Encroachment docok– 9/27/00 <br />