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WELL PERMIT APPLICATION FORM 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 /> nn ,,II (+ / Assessors (0- 6/3 <br /> WELL Location a 1S E/i 10t 01U111 k/f Cross Street -rTOOK�N City L 0-.n Zip �Parcel# obJ-b <br /> PROPERTY Owner <br /> /<6 l400kf �U9 ba„� Address (0/1 ©/'aa city taut Zip fl' f IIPhone# �O'Y&91a 00 C-57 Contractor N Pe Address PD 4x 603 city©rout Ilic Zip 9s <br /> ✓ Uc#g77L?0ry <br /> hone# 9y✓�� T <br /> ql— <br /> � tCtJk Lic# one# <br /> Consultant/Sub Contractor 1 1t/Nte1d(f INC Address � M <br /> GIS Coordinates:X ,Y.,Township Range_---C- i 3Na <br /> olq <br /> Section I J <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> aNEW WELL/BORING(CPT, EOPROBEGY#D�H�HAN�-AIZG R,fO�ER') aOVER-BORE <br /> Q W ELL# 5 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE / MULTIPLE CASINGS?BYES ONO WELL CASING DIA:NR <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICS n KNESTYPE OF CASING: p STEEL B PVC BOTHER, NA <br /> a VAPOR MUD ROTARY DEPTH OF GROUT SEAL-M bSvf C TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> a AIR SPARGE SH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: aMaA� XIMUM FREE-FALL DEPTH IS 30') <br /> FOIL BORING X'1 p HAND At71�G�E�R GROUT SPECIFICATIONS: e&+CC w <br /> l Fxw�o o✓r 1 Sl r) <br /> B OTHER: OTHER txe pry APPROX.BORING DEPTH /0 p BOLTED TRAFFIC 80 or STOVE PIPE <br /> (Q//�� <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: SA- Jam- 664 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4B WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby ce that I h ve pr ared this application and that the work will be done in accordance with San Joaquin <br /> County Or n ncey , / les a d Regulations, and all applicable California State Laws.//1I ( <br /> Signed x <br /> Title/Company //'D ee-f aeo1 1 <br /> Date � 0 <br /> Print Name C` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORKPLAN DATED: �[ <br /> / /! �„[� Date Issued 103 Area <br /> Application Accepted By Z Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> _ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMR/SERVICE REQUEST# <br /> 2(DI �4— /�— /6°1 D lJ� �3 v o0 <br /> C-57_ WC_-WAIVER—WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment dot_ 9/27/00 <br />