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WELL"OPERMIT APPLICATION F..AM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <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 9-111K <br /> and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> aotti Assessor's <br /> WELL Location i v Va zx a ross Stre t City Zip J�0 Parcel# <br /> (� (1 -sLb 1 (cootol�rRc��. .. �J <br /> PROPERTY OwnerL4 QLzo US� Vo ftbCt,?M4ddress 1,..x0 iv�t � CitySr�K dvt Zip 3 Phone#qZS' gq`9(oSS' <br /> C-57 Contractor_ � Address �s�__ city -ZipJ$ff5 �5�J& -hone# _• <br /> Consultant/Sub Contractor©1=, Address 3017 � amore �J ��� CityQan1,,,C.a- 'c# Phone# 301'NCO <br /> GIS Coordinates:X 'Y Township Range Section <br /> K <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT, EOPROBE,HYDROPIJ CH,HAND-AUGER,OTHER*) []DESTRUCTION(choose type below) <br /> tSOIL BORING# �(� []OVER-BORE <br /> []WELL# []PRESSURE GROUT <br /> *Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?[]YES �VO WELL CASING DIA:--,— <br /> EXTRACTION <br /> IA: -EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS 4) I� TYPE OF CASING: []STEEL []PVC []OTHER: 01/8 <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL PI TREMIE TYPE TO BE USED: []AUGERS SE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: es No (NOTE: MAXIMUM FREE-FALL DEPT IS ') <br /> ROIL BORING []HAND AUGER GROUT SPECIFICATION P P <br /> []OTHER:—[]OTHER APPROX.BORING DEPTH I� []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? F' (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br /> * <br /> CALL TH I ECTOR 48 WORKING HOURS INpADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x T 4 Title/Company ►� s S,�, A <br /> q Z� <br /> Print Name Q2.P tJ 1`�O- Date 2 C <br /> COP <br /> SITE MAP IN UNIT IV FILE ADDRESS/WORK PLAN DATED <br /> -,--- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By f Date Issued /C o Area <br /> r ....•�. . Date < o r Final Inspection By M�<`e—� Date S /7--- <br /> Destruction <br /> Inspection By ,��a-t.1 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cerrK <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 '01 �-�.�0 cc)'fZ_ 4y� CX 51fC'/ I SR# oo a (:;' I 1 <br /> C-57 WC/WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/12/00 <br />