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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 />Assessors <br />WELL Location6�3� �`ff ���i�"�"i 29 Cross Street �4�r�ti�lJ L-1City Zip 95 Parcel# <br />PROPERTYOwner M5. Lolly /jo224no Address 2991 Nor4 4mylo- 41. CiZip 95?15' Phone#061931- 64g7 <br />/ la #ne S50 elver eJ- Ci "0 1%1S�i 'W71 7/0079 #(�07) 3 N-N3o� <br />C-57 Contractor Woo �i,�lurd �r� Iii»y Address ty � p Lic# Phone <br />Consultant / Sub ContractorA T( ksoe;o4e5 , To e • Address 1// 7 Loht 'Qw, 4",_ s/,Al dtSf� Lic# Phone# (,2o?) 579-.2,2,2 <br />GIS Coordinates: X <br />Y <br />Towns <br />WORK TO BE PERFORMED: <br />NEW WELL /BORING (CPT G ROB HYDROPUNCH, HAND -AUGER, OTHER*) <br />SOIL BORING # 3 (�to�rob�S <br />0 WELL # <br />Grout Specifications:_ <br />8o -8S" bqs• fi0r <br />'Other: <br />COMMENTS: <br />50Mpl,-- (�r0m Carl+ 40r) <br />Range <br />Section <br />DESTRUCTION (choose type bek4v) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE ; PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />0 OTHER:_O OTHER APPROX. BORING DEPTH S ff• 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS <br />NOTF- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRLU INZ�rtc; I JUNZ-j. <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 <br />lState <br />' Laws. <br />Signed x /V�'- <br />,,J/��,/ `'��f%"- <br />C-"om_ Title/Company Sl �l7 { GCdId�%s 7/ / ATC 4SS6r1471rs, Tkf , <br />Print Name �GT�1 G 0 � � r t 571'P"e4 'I Date /— 6 - O Y <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD ESS: <br />WORK PLAN DATED: D <br />to 3 <br />+ I 5 -7 <br />Application Accepted EB <br />Grout Inspection By <br />J Date <br />Date Issued a` <br />j -q MIK—Final Inspection By <br />I I <br />v <br />Area Z <br />Date <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: E <br />PE CODES FEE INFO AMOUNT REMITTED <br />351 �� ��VV <br />CHECK # <br />REC'D BY DATE <br />►i cSSR <br />PERMIT SER <br /># INVOICE <br />C-57 `.NC -WAIVER_ C-57 Letter of Authorization to Sion permit <br />Encroac ment doc_ <br />9/27/00 <br />