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ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 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 /> / `15 YO' - Assessor's `/ <br /> WELL Location ,31dC' t�ak+yl ✓G1 Cross Street City �1'nfCT Zip `/s 7 Parcel#_,) i1-OCC -U 7 <br /> PROPERTY Owner Address 33 y res f F/�"� I/ City 54;, Zip`/f dc-) Phone# <br /> C-57 Contractor C:rs<<`.1� Address 3C1•ti11C C;•,/" City�cr« .n,gfr�Zip`l )'/ <br /> 6f Lic#1/ 15i6) Phone# t9�G)�t� 1169 <br /> Consultant/Sub Contractor .Sf cG'/'� �r'� i rev„ Address �o/7 % y��e, _City '4r G, Lic# Phone#l"rb f yc/ y ypn <br /> l/ C L•.. <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AU(KR,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BORING#_ []OVER-BORE r 1 <br /> #WELL A 4AA []PRESSURE GROUT ; <br /> 'Other: Grout Specifications: �-- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS?[]YES []NO WELL CASING DIA:<7 <br /> [] EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS 5-� `� TYPE OF CASING: []STEEL []PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL f5 TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: yda t C�•K�•�-I <br /> []OTHER: []OTHER APPROX.BORING DEPTH ai []BOLTED TRAFFIC BOX or [KSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BO INGS REQUIRE ACCES9 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 /> 7 /vL.�� S•Fc<'i` �'/n Pyr Sc �.r,,�frf f <br /> Signed x Title/Company <br /> Print Name r< P` T, e / Date (0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: &-ff / -4 <br /> WORK PLAN DATED: �- ') <br /> Application Accepted By Date Issued /v I Area <br /> Grout Inspection By Date Final Inspection By 1: ,. ' Date -7-24,-02— <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: ZZ <br /> ACCOUNTING ONLY: AID# <br /> CAf ti <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REQ06 BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 40 �� sit 2 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc04 9/27/00 <br />