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WELL PERMIT APPLICATION FORM <br />NI�.,: <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />G� (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />oaquin County Development Title, Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />HELL Location 16 C3 s Q S 2— Cross Stroet eti'A-Q me w+✓ City s72t,,--AZM v _Zip_2L20.5' Parcel# <br />>ROPERTYOwner G44re4W..9 Address /Q76 E eAtfero,2 City�7aN Zip 9SZaSPhone# ZO VVB- A-3 <br />-57 Contractor � GJ_Address f O 411A City c rb�2ip 9y641 Lic# �1�y Phone# 916 777- Y/00 <br />:onsultant / Sub Contractor Address City Lio# Phone# <br />;is Coordinates, <br />Y <br />Township. <br />NORK TO BE PERFORMED: <br />4EW WELL I BORING ( CPT. GEOPROBE, HYDROPUNCH. HAND -AUGER, OTHER') <br />o SOIL BORING # <br />0 WELL ti /}? W - / 5( _ <br />Other. Grout Specifications: <br />COMMENTS: De.Sr12ycT/oN <br />rYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />A, IOLLOW STEM <br />EXTRACTION <br />[I AIR HAMMER/DRIVEN <br />7 VAPOR <br />[I MUD ROTARY <br />AIR SPARGE <br />fl PUSH POINT <br />j SOIL BORING <br />a HAND AUGER <br />I OTHER: Q OTHER <br />Range, Section <br />DESTRUCTION (choose type below) <br />lktVER-BORE <br />PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS �� <br />DIA. OF BOREHOLE/O=' MULTIPLE CASINGS?[)YES NO WELL CASING DIA-�' <br />CASING THICKNESS ­: k n TYPE OF CASING: [ISTEELPVC 1] OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USUN <br />ED: IJ AUGERS (�I-IOSE <br />GROUT SEAL PUMPED: Eyes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') v <br />GROUT SPECIFICATIONS: N�4TTGL} vo C�cn►G-✓T f �9 L�'��""TC 7 <br />APPROX. BORING DEPTH /49,0' QceoLTED TRAFFIC BOX or O STOVE PIPE <br />CONDUCT6R CASING PROPOSED? /VO (if YES. list specifications 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 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordin. s, Rules and Regulations, and all applicable California State Laws. <br />Signed x `�`' Title/Company �RaSG` <br />Print Nam/, - <br />am --5'� IV Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADYRESS: <br />WORK PLAN DATED: / <br />Date Issued 6 Area <br />Application Accepted 8y DaL-- <br />Grout Inspection By U�-^ <br />Date t Final Inspection By „2 w date 1 ti <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMrrTED CHECK IF REC'D BY ]DATE PER QUEST # INvoICE <br />3 �Z �O o� o��zg s cZ�do <br />C-57— WC= WAzVER— C-57 Letter of Authorization to sign permit Encroac men oc 9/27f00 <br />