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I � '� �,� [ /ELL REI�MIT APPLICATION FORM SITE <br /> DEC 1 0 200SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> NVIRUMViENT HEALi 304 E_ Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (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 ofSanJoaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location Z0 q./u i./�/✓� Cross Street City tih Zp arcel <br /> PROPERTY Owner G/" fi�,�J�rgD,,, Address_�j 9PX LZZ(,2 City, Zip-4' <br /> A Phone#53D 7573 S696 <br /> C-57 ContractorAddress 3g�3 �.�17GG Cily �Z1�5>9zLict ��75.T Phone#t 9j,� �3 // <br /> Consultant/Sub Contractor Address,/O_. �JOX /O�� City lCJ a,Lic#5���✓YPhone#9/6 3?.Z 7S 3S <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# A A I j I 0 OVER-BORE <br /> ,pdWELL# — / D PRESSURE GROUT <br /> 'Other: Grout Specifications:fvls�l4,nr�GG,�t.,nJ� .�//3% /QGr,�; <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING gHOLLOW STEM DIA_OF BOREHOLES' MULTIPLE CASINGS?[]YES XNO WELL CASING DIA: .Z�� <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS6&o�,.o'y® TYPE OF CASING: O STEEL ,XPVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL /O TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: 0 Yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: % 9--o-_ Qct! <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH .?S , BOLTED TRAFFIC BOX or [I STOVE PIP <br /> CONDUCTOR CASING PROPOSED? (if YES,list speclflcatlons 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 Ordinances, Rules andReAulaticys,and all applicable California State Laws. <br /> Signed xTi <br /> // tle/CompanAll <br /> y Cl�i/I��oJ����.�����Gd✓ <br /> Print Name �/KGy A' 'K/ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By `= Date Issued <br /> Grout Inspection By Dat 710 Final Inspection By Date <br /> Destruction Inspection By /Date / <br /> COMMENTS/CONDITIONS: VI W Z t <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D SY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authotza on o sign permit Encroachment doc 9/27/00 <br /> 1 <br />