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URIbINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> PVIRONMENTAL 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 ) /C%L V�c�ti S:'r] /\�R Cross Street �- - 5 City 11:+v; ( Zip `i s -1 7 Parcel# <br /> PROPERTY Owner Address 3 �"7 f Cr r,r+n,r/ City 11 Zip 7S �r>.)Phone# <br /> r, X11 / � t � <br /> C-57 Contractor �,i ti 1t rdl OAddressjlfJ (��� I(� r, ��( ,_ City S Zip Lic#51 J ��6one# _ (� <br /> Consultant/Sub Contractor ``V k f' ''`�'° Address 5 r'I 1 IC 'City f�"�' /' C`/C <br /> Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: 9-) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING •HOLLOW STEM DIA.OF BOREHOLE ' MULTIPLE CASINGS?B YES 0 NO WELL CASING DIA: _ate <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �! '/' TYPE OF CASING: 0 STEEL B'I VC BOTHER: Cj <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1` TREMIE TYPE TO BE USED: B AUGERS 0 HOSE 5 <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes B'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �}}}'J------ <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH t 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? �'r' (if YES,list specifications here): <br /> 'COMMENTS: <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 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 �`- '~`�1 C�ili . Title/Company <br /> Print Name -' • 4` 14-4 r 1 "`' Dale _/;z <br /> DEPARTMENT USE ONLY <br /> � <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 3-I -02 <br /> 77 <br /> Application Accepted By Date Issued 0 v Area <br /> Grout Inspection By Date Final Inspection By Dale <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 /> Z OF/ x--13 SR# QOJOCl)� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit E/ t doe 9/27/00 <br /> ` <br /> T/c <br />