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WELL RMIT APPLICATION FOO <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 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <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 <br />WELL Location G . Cross Street 101A on ityZip_ Parcel#_ - <br />PROPERTY Ownerc�i c"W OL�.-C AIArrrdclreskb, %)I LAUD Ci ip-1U✓�Phone# -q (DCj� <br />Cj C-57 Contracto O �1 a rl Ad�� ) ikO t,l?�K-QC - C _lhg�- <br />b-C /��� <br />Consultant / Sub Contract - idresS— CiPhon a <br />GIS Coordinates: X Y Township—?�, Range _._. Section 3 1 <br />WORK TO BE PERFORMED: <br />Date Issued ?/ L Area <br />�d(NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />Date Final Inspection By Date <br />/,V <br />[] SOIL BO NG # 0 OVER -BORE <br />-Z <br />Date <br />-E14NELL #( JA —� rCC� Q %tib 0 PRESSURE GROUT <br />�J <br />*Other: Grout Specifications: <br />—���r �f`G <br />COMMENTS: <br />S <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />(r <br />HOLLOW STEM DIA. OF BOREHOLE " MULTIPLE CASINGS? 0 YES'-'aJNO W ELL CASING DIA: <br />,,VMONITORING <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS tr TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />n <br />C. - <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:'4--Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />0 OTHER:—0 OTHER_ APPROX. BORING DEPTH OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 Or • ances, Rules a egulations, and all applicable California State Laws�.,� <br />Sign Title/Company af7^ Sae UJ, ► / �t�l_ � � ►yCx l <br />Print Name Date r <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Date Issued ?/ L Area <br />Grout Inspection By <br />Date Final Inspection By Date <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />�5G <br />ACCOUNTING ONLY: AID# Genu <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'DD/ BY <br />DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />�5G <br />y <br />—���r �f`G <br />lL �yJ/ <br />RR# ^ <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroa 9/27/00 <br />