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o/- <br /> j <br /> LucwerFORM SITE <br /> WELL PERMIT APPLICATIONMITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 d�j <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to SaleJChaulte County9--11for a 5 3 and the Standards f Sant to construct /Joaquin or l Coun y Public Health Services,the W0[K described. This tn�Environ is nmental al Health e in IDivision. <br /> San <br /> Joaquin County Development Ti p Assessor's <br /> r��, ��r� ( Whu FT7e.Ci C'G ` Parcel# <br /> WELL Location s =l Cr°ss Street ry <br /> ! -d(/ Ci ZiKPhone# <br /> PROPERTY Owner W�OLIVA l' Address 4&/,- y <br /> Z*i/ 51214,VVAM city GYM T �i Lic#'f7 t4hone# <br /> C-57 Contractor �L�—I��1 1.�( Address � � �7 ! q <br /> t LL. �L � fAD `C� _CD( Lic# <br /> Consultant/Sub Contractor �i lL dress <br /> Range Section <br /> Y Township <br /> GIS Coordinates:X - <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT, <br /> CPT,GEOPROBE,HYDROPUNCH,HAND <br /> 0 SOIL BORING# ` 0 PRESSURE GROUT <br /> 0 W ELL# 2 TI Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL IN ST CATION TYPE CONSTRUCTION SPECIFICATIONS ULTIPLE CASINGS?0 YES NO WELL CASING DIA: <br /> 0 MONITORING OLLOW STEM DIA.OF BOREHOLE TYPE OF CASING: 0 STEEL � /C 0 OTHER: <br /> VXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: frA 9„OS` <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2- <br /> E-FALL DEPTH IS 30') <br /> 0AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOT Gly FRE <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 7 J5A1r-k LTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH aRv <br /> CONDUCTOR CASING PROPOSED?_� i Q_(if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCIESSS OR ENCROACHMALL ENT ENT E CTSI. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS <br /> I hereby certify that I have prepared t application and that the work will be done in accordance with San Joaquin <br /> County O nces u s d Reg a ons, and all applicable California State Laws. <br /> Title/Company <br /> Signed x <br /> Date <br /> Print Name iFAMfA <br /> .7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: -�2 <br /> �— Area <br /> Date Issued <br /> Application Accepted By <br /> Date Final Inspection By `° "" °�Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3g- £s-15 - X30-1601 Nwj �o <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment docW <br /> 9/27/OC <br />