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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 2�ti p , ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 02 304 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 /> Agfwyi'c' �' Assessor's <br /> WELL Location�� �� �_aT. Cross Street CityZip Parcel# <br /> 7e S Address �r' city. 5r T zipT`'���hone# <br /> PROPERTY Owner <br /> ��- y�s�6B <br /> C-57 Contractor 2"Al Address ity p. Lic# Phone# <br /> Consultant/Sub Contractor r9ss_1;7 .4!C City 4PAiWO/ Lic# Phone# Ql6 '�Seo D <br /> d <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HANG-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> Q SOIL BORING# 0 OVER-BORE <br /> 0WELL# []PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 119"I MULTIPLE CASINGS?AYES B NO WELL CASING DIA: �" <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESSJ� �TYrI;E OF CASING: []STEEL APVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL J TREMIE TYPE TO BE USED: gAUGERS []HOSE <br /> AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMU FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: 4154!77 66�� <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH � IktOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ,/?) (if YES,list specifications here): <br /> *COMMENTS: 4 <br /> m F L/rt- - V <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENrROACrIMENT 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 Ordinances, ;ulsnd Regulations, and, able California State Laws. <br /> Signed x �� �all ppiicTitle/Company / � tT7D�tl� <br /> Print Name GG Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ?-0 S Sit er -t <br /> WORK PLAN DATED: 3 12--2- p 7- <br /> Application Accepted By Date Issued / D Area <br /> Grout Inspection By Date _nal Inspection By Date <br /> Destruction Inspection By Date 1 L <br /> COMMENTS/CONDITIONS: { <br /> ACCOUNTING ONLY: AID# cnr+r <br /> PE CODES FEE INFO AMOUNT REMfTTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 f4 $$q' Szo3�7 �t� s r az SR# 40�.t)6 Z <br /> C-57 WC -WAIVER C-57 letter of Authorization to sign permit _Encroachment doc 9/27/00 <br />