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0 0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT 1V <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 /> Assessor's <br /> WELL <br /> WELL Location S I,✓ �`� WA`s Cross Street S L�✓� ��NCity % r � Zip J L-9(; Parcel# j y7---)7!y <br /> PROPERTY Owner �Address Zip �Phone#//y�C 5� <br /> C-5T Contractors/15L��G" (�nitLlti'> Address 3E3z �f✓j�L LI(�GLL CityZ/D�-A Zip Lic#�i�5(0Phone#���/b��l�S—//E�> <br /> Consultant/Sub Contractor 14AW L}s IAA� AddressOU '✓ 14ARriy/ /340 City`J.!4L4"ce?ic# Phone#`4( '�/'Z`S' 33- ) <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> a.WELL# 0 PRESSURE GROUT <br /> 'Other: rout Specifications: <br /> COMMENTS: Lvl;'l,L PJIR <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 7 / <br /> .N�MONITORING XHOLLOW STEM DIA.OF BOREHOLE / MULTIPLE CASINGS?0 YES ](NO WELL CASING DIA: Ci <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 1� �/� TYPE OF CASING: 0 STEEL :'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL II" AyD 11 TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: J(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: L45AL'Nf C'R� <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 59' A'; 1P `SDS BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Al) (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 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 Ordina s, ules and Regulations, and all applicable California State Laws. M <br /> Signed x Title/Company 0 Q2 (-CL S ' `�r C aSCa- �g <br /> Print Name <br /> �. �fi� C. Y \ Cil Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �i l L✓ L��R�L'R L✓/4'y <br /> WORK PLAN DATED: P/3 IL 12 ZZOz, <br /> Application Accepted By 4')-cam+.^^ Date Issued Area <br /> Grout Inspection By Date Final Inspection By -Date <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 /> slit <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />