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WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH nIVISION (PHS-EHD) <br />304 E. Weber, Thlyd Floor, Stockton, CA., 95202 <br />(209) 468449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Jcaquin Count' for a permit to : onstruC and/or install the work desalted. This application Is r jade in compliance with Sar <br />.loaquin County Cevelopment Title, Chapter 9-1115.3 and t ..e Standards of San Joaquin County Public Health Services, Enviror rental 'r.eal:h Division. <br />/ / ecAssessor's <br />WELL Locatlon_ 7 �� 111; 4d Cros� <br />s SLoet A#(, kA, l City Sj"An/ 1 Zip _, cet# <br />PROPERTY Ov nefFL4 /l ie►"+�►N1u Address 1Or1 N; UUA'J1s 20c j City S IoLl�ku�. ZipJ5209 Phone# 47B- 1614 <br />C-57 Contractcrlj ecT Uwe SKr t itr Adcress Z36S wCIty_SJp�k a Zip.95205 L cT St zb P^ones q1,5Rl l 2 - <br />Consultant,' <br />Consultant,' Sub Contractor (_rouNa 2$re, Address Lic# Phone# <br />GIS Coorcinates: X-... _ , Y <br />Township <br />WORK TO BE PERFORMED <br />EA! WELL r EORINC (CP-, GEOPROBE, HYDROPUNCH, HAND -.AUGER, OTHER-) <br />11 SOIL BORING # <br />WELL# YIA1•11 <br />'Other. Grout Specifica <br />COMMENTS: <br />Range Secttr <br />0 DESTRUCTION (c.-oose type below) <br />3 OWER-SCRE <br />G PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />XIVIONf'ORING X-IOLLCW STEM DIA. CF BOREHOLE g r, MULTIPLE CAS NGS7 p Y_S O N:3 VJErI L CASING DIF.: <br />p EXTRACTION [, AIR HANIMER'DRIVEN CASING THICK1,ESS3,In 4O Tl rE OF CASING p STEEL PVC p OTHER: <br />11 VA'OR h MUD ROTARY DEPTH OF GROJT SEAL Z3 ' TREVIE -YzE TO BE USED' AUGERS 11 H, -)SE <br />p AIR SPARGE n -USH PONT GP.OJT SEAL PUVPED: 9yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORiNG 0 HANG AUGER GROJT SPECIFICATIONS: j v'bA no'.A `'/51. l-jeii"kA+ <br />0 OT=ER' _0 CTHER A=PRCX. BORING DEzITH Z4_71 �K2GLTEC TRAFFIC 5CX or OST 0'/E PIPE <br />1 CONDUCT -OR CASING PROPOSED?P, �b f YES, lis: spec ficaticns here). <br />•CCh1MENTS: (� l' t A <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or ina ;,�ules and Regulations, and all applicable Callfornia State Laws. <br />Signed x IJ Tit e/Company <br />Print Name—rGlC leaf Date 5 1$ ,(D 1 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: -ib p\ 1)p t s 12rsc�c-r' <br />WORK PLAN DATED: `1 J I G c I <br />Application AccepteC By i Dare Issued Area <br />Croat Inspection By �,��1,�...�r oft , _Date E t` f Firal Inspealon By Date <br />Destruction r.soecticn By Date <br />11 rr Ni�f <br />COMM1IENTSICONDIT10N3: 1\:C'TI � _ I 777 tr <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK 9 1 RECD BY I DATEI P�RMITTSEl W6�&EEUEST # I INVOICE <br />c-,(7, <br />C-57_ WC; WAIVER C-57 Letter of Authorization to sign pertmit_ Encrooc., c_ 9/27/00 <br />T <br />v <br />