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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH 01VISION (PHS-EHD) <br />304 E. Weber, Th1rd Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application Is hereby nada to Son Jcaquin County for a permit to wnstruct and/or install the work descrlbed. This application Is rade in compliance with Sar I <br />.Foaqui-1 County Development i itIc, Chapter 5-1116.3 and the Standards of San Joaquin County PuSilc Health Services. Enviror rental Health Division. <br />e_ Assessor's <br />WELL Location_ o ��5 L� /.i9UlS � dl Cross Stmet r �G� city � Z p 0 9 Parcel# <br />// J <br />PROPERTY Owner �ll lI u..a�AW _A.ddresseZ)5 5 �c �) City _Zip95lOti Phone# VS -MN �3 <br />C-57 Contractor SrJ�r,nti, f1Ln�vtMtii� Adrress��LCA?� City 'k i Lp_f..�Lc#5t2uY P^one# S- &7 1.2 <br />Conauitani; Sub Contractor LN�17x/D Address /2/4/ >R*11 Sk <br />j%�CityE Lich Phcne# 9313-SS'k� - <br />GIs Coorcinates:X___ <br />Township <br />W RK TO BE P <br />'JI -NEW WE1,0 ECRING EOPP.OBE, HYDROPUNCH, HAND -AUGER <br />SOIL BORING <br />11 WELL# <br />'Other: <br />COMMENTS: <br />Range <br />Sec tr <br />�J <br />OTHER-) 0 DESTRUCTION (choose type below) <br />0 Cb'ER•BCRE <br />Q PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 NtONITORING JI-HOLLCW STEM DIA. OF BOREHOLE MULTIPLE CAS NGS', 0 YES 0 NG WELL CASING DIA: <br />[] EXTRACTION C AIR HANIMER,'DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL p PVC 0 OTHER: <br />[] VAPOR Ll MUD ROTARY DEPTH OF GROUT SEAL 30 TREMIE TYz'E TO BE USED' ff-AUGERS 0 H:1SE <br />p <br />AIR SPARGE 0 EUSH POINT GP.OJT SEAL PUVPED: ,E]-Ses 0 /N/o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROJT SPECIFICATIONS: ((rYl / ;�Wwl( <br />0 OTTER: _E OTHER AzPRCX. BORING DEPTH 30 0 90LTEC TRAFFIC BOX or 0 STOY° PIPE <br />CONDUCTOR CASING PROPOSED? (YYES, lis: spec'Tcations 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 ave prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord' an a, es and Regulations, and all applicable California State Laws. <br />Signed x / Tite/Cuinpany <br />Print Name Date I/Ar,/O t <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ( & G^ <br />—T <br />Application Accepted By 4 Date Issued I r C I Area <br />Croat Inspection By (. �n tnC� Date Z Final Inspection By ',u,—Cate L/ <br />DestrLction irspecticn By Date <br />COMMENTS f CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFOj AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT/ SERVICE REQUEST # INVOICE <br />C 57_ WC= WAIVER! C-57 Letter of Authorization to sign pe^m,11Z Encrooc rnent doc_ 9/27/00 <br />