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H <br />�_ �; _' ��,' WELL PERMIT APPLICATION FORM SITE <br />�� � I! U I� U TION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br />AUG 2 1 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />IV <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SER'J1CFS (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 />1 4/.\,/ Assessor's <br />WELL Location .-rr �� r `S� Cross Street tl� City 9n 17 �i` Zip�S1�J'7 Parcel# ZS0 090- Z_j <br />PROPERTY Owner Q1er ,r 0 100Cc, Address J`�l S -1L City / z�i l7 ZipUS:'6"{ Phone# 2_0q •5U3j 275%� <br />C-57 Contractor (NJOG(WidDrr/1I(�'hAddress Po ,YlI City�,{� ✓'��Zip9'iSit Lic#7/u?I Phone# <br />Consultant / Sub Contractor/19L EA -,J rotCc 6x Address 7541 /i%u(ltScYi 14rr— City Mr P,6t 4 <br />Lic# Phone#( -?/(C 535 0760 <br />GIS Coordinates: X Y Township Range Section z4 <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />r - Ar 1 0 WELL # 0 PRESSURE GROUT <br />'Other O"I'fr LLL Grout Specifications: <br />MENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />AiOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />)GAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_ 0 OTHER <br />'COMME <br />DIA. OF BOREHOLE IO" MULTIPLE CASINGS? 0 YES J�,NO WELL CASING DIA: '-I 0, <br />CASING THICKNESS_ Vv LO TYPE OF CASING: 0 STEEL PVC 0 OTHER: kA <br />D,EPTH OF GROUT SEAL TREMIE TYPE TO BE USED: �kAUGERS 00 HOSE��� <br />GROUT SEAL PUMPED: 0 Yes ANo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: J �i71Fi 1 S i�C'12�f�YLC �C C �S <br />APPROX. BORING DEPTH 2 % BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? d(L) (if YES, list specifications here <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 />CountynOrnance�, Rules a d Regulations, and all applicable California State Laws.// -- <br />Signed x / Title/Company Cy scl . Z/2T:: � '- _y/ t K C 'l <br />Print Nam Ci17 " Lt > > le— , Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD ES . <br />WORK PLAN DATED: <br />Application Accepted By�� , Date Issued Q,-), ( Area <br />Grout Inspection By Date g�(4- 0) Final Inspection By Date&�L <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: E -J. -y' l I� )1 ( (- --7.-44/L i-) %�t�i L C 'A -X_ \ 777-C <br />7 - <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT /SERVICE REQUEST # <br />INVOICE <br />J <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />