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WELL PERMIT APPLICATION FOKM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 />_ Assessor's <br />WELL Location /.�0 5 C JAS''" Cross Street b•'J `� City 5 {uLIC�o Zip cls-i5� Parcel# I t <br />PROPERTY Owner •��� u I fo.l C.. Address P`), 4-x 3 Z is CitySlv( k)�i Zip 15 Z= / Phone# <I(o l - `b T�3 <br />D J nnx?- Lic# �1E <br />Zip `, <br />C-57 Contractor �� fl" f Address 3 3 � City 1�i� Jti L1 }I `�'M'Phcne# 3 -74 _y ) JJ <br />Consultant / Sub Contractor AV( C N1'S�� `�' � Address i,(>— � t ^^ City �t�� Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type beloYv) <br />0 SOIL BORING # 0 OVER -BORE <br />k4ELL # 0PRESSURE GROUT <br />*Other: Grout Specifications. S <br />COMMENTS: Q <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSft,`J <br />MONITORING RIHOLLOW STEM DIA. OF BOREHOLE `D MULTIPLE CASINGS? 0 YES 4 -NO WELL CASING DIA: Z s <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �J<<^`(� TYPE OF CASING: 0 STEEL )a -PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL G TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Q �`� 0� _ <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH Its BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CLONDDUC_TOR_ •CASING PROPOSED? P3 (if YES, list specifications here): <br />'COMMENTS:_ f oo <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 Ordinance's] Rules and Regulations, and all applicable California State Laws. <br />f��n� Vim Title/Company &.ago✓ l �roJ rri♦ N)o <br />Signed x `` <br />Print Name ' z,,-' " �" �l` Date Z� r Z y <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />�O _��S_ <br />I,, S'S+C'C'fc- `— <br />WORK PLAN DATED: II 'lo O <br />Application Accepted By Gtr <br />Grout Inspection By_l��.uw�o�� <br />Da1 <br />Date Issued 2_1 <br />Final Inspection By <br />/ <br />Area b Z� <br />,ate .we -ave Date Z 0 <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />n II`` 2 <br />^ V U J <br />PE CODES FEE INFO AMOUNT REMITTED ___FCHECK <br /># <br />REC'D BY DATE <br />IT / SERVICE REQUEST <br />INVOICE <br />3 So l 46 -0 C <br />( j- <br />� �3 ° <br />C-57_ WCWAIVER_ C-57 Letter of Authorization to sign pe rmit <br />= <br />Encroachment doc_ <br />9/27/00 <br />