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WELLIP'ERMIT APPLICATION FORM
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)
<br />304 E. Weber, Third Floor, Stockton, CA., 95202
<br />(209) 468-3449 ORIGINAL
<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 />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 Location 311c 'TaLcl s?)1k). Cross Street I.), t..,iikrstAN Q. City ‘ fc..C.Ai
<br />
<br />I
<br />Zip I ,7 C3 Parcel # 2 12.-11b- 2i5
<br />Q ......,
<br />PROPERTY Own .. ,.s., n Vrbc\,,.&,D C., a) er..,4 A ress G001 /4.,..4invzrz.. (Ic.' L-1;.,..t.;,r1 City e;AoiN 3414..cr., .j Zip Q1c-ICE Phone# c ZS-41Z- 76,2---
<br />€)1=',1 azta4.0.6e, , _14/70q,,TTOP e' 7)— 'r —
<br />
<br />Address City Contractor, 'Address hcrokk.. City IP 1Agt. ;,)o-p. ziruirli, L1c.'"..1 Pho
<br />Consultant /Sub Contractor 66.(D'il._ Address .SC>ll tN\c,::..-re./OD CityAok,,Lic# 6.:51.14ctb Phone#
<br />GIS Coordinates: X Y , Township Range Section
<br />OIASike. vr\
<br />INSTALLATION TYPE
<br />fi HOLLOW STEM
<br />rj AIR HAMMER/DRIVEN
<br />[] MUD ROTARY
<br />U PUSH POINT
<br />0 HAND AUGER
<br />OTHER tiACA
<br />cs-s
<br />DESTRUCTION (choose type below)
<br />El OVER-BORE
<br />El PRESSURE GROUT
<br />CONSTRUCTION SPECIFICATIONS
<br />DIA. OF BOREHOLE v`3 '1 MULTIPLE CASINGS? ['YES \festi2 WELL CASING DIA:41A
<br />CASING THICKNESS ),-)in- TYPE OF CASING: I] STEEL a PVC [] OTHER:
<br />DEPTH OF GROUT SEAL IA TREMIE TYPE TO BE USED: flUGERS 0 HOSE
<br />GROUT SEAL PUMPED: X'es L No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />GROUT SPECIFICATIONS: 12..A__ Cr.--)VvvU•A-
<br />APPROX. BORING DEPTH '3C) e 0 BOLTED TRAFFIC BOX or fl STOVE PIPE
<br />CONDUCTOR CASING PROPOSED?1\...\0 ( if YES, list specifications here):
<br />COMMENTS:
<br />TYPE OF WELL
<br />MONITORING
<br />O EXTRACTION
<br />I] VAPOR
<br />AIR SPARGE
<br />176....EAL BORING
<br />0 OTHER:
<br />*COMMENTS:
<br />WORK TO BE PERFORMED:
<br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER)
<br />SOIL BORING #
<br />ELL #
<br />*Other: Grout Specifications:
<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 Ordinances, Rules and Regulations, and all applicable California State Laws.
<br />Signed x Title/Company .00 <\ P1/4
<br />Print Name .12-1 42'•
<br /> Date 16 1C-161
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADDRESS: Tha-.7e,/
<br />WORK PLAN DATED: / /
<br />Application Accepted By Date Issued
<br />Grout Inspection By Date Final Inspection By
<br />/0....,A/
<br />Destruction Inspection By Date
<br />COMMENTS! CONDITIONS /41C-62..> 4 4"Jj. , ke; I
<br />ACCOUNTING ONLY: AID#
<br />FAC#
<br />-11..
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE
<br />..F t_-/ 19, Y.--q' ./r/i6 /%/// $R# OY36 s?"
<br />Area
<br />Date
<br />C-57 WC -WAIVER
<br />
<br />C-57 Letter of Authorization to sign p rmit Encroachment doc
<br />
<br />9/27/00
<br />
<br />CEVE89V606 TE:ET 000Z/VO/7i
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