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ti <br /> 0 J Q WELL PERMIT APPLICATION FOM SITE <br /> w CDMITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC EALTH SERVICES UNIT IV <br /> -�� <br /> Z' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Q r <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> � � (209) 468-344 <br /> © �_C1. <br /> U-1 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 /> -7 Q `- I 1 Assesso s <br /> WELL Location Z" l W 4L44v``0"M L011`Cross Street 401- v'`S n C. City ba 6,, Zip�5L40 Parcel# D 0 87 <br /> PROPERTY Owner �`�iSN �nJ o v-, _Address $y�'N. L\a tiA City L��i Zip `t5 Z`E4�10hone# <br /> I <br /> C-57 Contractor S t��wrvt �'ti\��7 Address Z5t-5 �Jj Ci' SlU�Y-I•- Zip Lic#51I-ZP'6 Phone#L-LtOS- <br /> ConsultantISubContractor ��� � �' `A � Address ��,� ��,`^^ 't3 City 1�a4Uc# Phone# 5 —zZZI <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFdRMED' <br /> �WNEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER' n DESTRUCTION(choose type beloyv) <br /> o SOIL BORING# 0 OVER-BORE <br /> '.WELL# jl PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS << <br /> 0 MONITORING )riOLLOW STEM DIA.OF BOREHOLE {S MULTIPLE CASINGS? 0 YES �1 0 WELL CASING DIA: �o j <br /> V9XTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSS0- TYPE OF CASING: 0 STEEL )R�PVC ©OTHER: <br /> 0 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> a AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: ,f'Ye []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 4 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: OTHER APPROX.BORING DEPTH 'O ` ji-BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPO ED? (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 INADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the Work will be done in accordance with San Joaquin <br /> County Ordinances,V#Zules andRegulations, and all applicable Cal fornia State Laws.Ti� )\N%. � C tS <br /> Signed x ��� TitlelCom any � <br /> Print Name O>f'tr-, Q"^ Date <br /> DEPARTMENT US E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Byate Issued,�oo I - —Area ��9� <br /> Grout Inspection By Date 10 - d I _Final Inspection By Dater <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT7r, PERMIT I SERVICE REQUEST# INVOICE <br /> 9/27/00 <br /> C-57 WC=-WAIVER-- C-57 Letter of Authorization t Sign permit Encroachment doc <br />