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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH bIVISION (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 mads to San Jcaquin County for a permit to construct and/or install the work described. This application Is r jade in compliance with Sar. <br /> oaquin County Development lift Chapter 5-1116.3 and tt.e Standards of San Joaquin County PuNic Health Services,Envircr rental'H.eal:h Division. <br /> Assessors <br /> WELLLocatlon_ Cro3sStrect City Deli zp _Pareeo &(Aq--o5'2 3 <br /> PROPERTY Owner N !L& ,ftnv. _Addess 4A.? a hied, C;N_ ZP SZlut Phone# <br /> C-57Contractor N)� ) br-,IJL,ko, Adcress ICO 5 S1tec City Ie Zp_o96y) Uc# F-cne4(914)771-4IUU <br /> Consultant;SubCentractor —Address HILI WLI.IM S P.2� City Li_-X Phcne# <br /> GIS Coorcinates:X__._. ,Y ,Township Range Sr r•`cr <br /> WORK TO BE PERFORMED_ <br /> IE-01 WELL r ECRcIf•iC(CPT,GEOPROBE,HYDROPUNCH,HAND-.AUGER,OTHER-) 0 DES RUCT10%(c.,,00se type below) <br /> Q SCIL BORING z D OVER-BORE <br /> WELL# WlW ID [PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COM IAENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u <br /> ')t<1ONrTCRING C-'OLLCW STEM CIA.OF BOR=HO'E_6„MULTIPLE CAS NGS;Q YES ONO V7_LL CASING DIA: z <br /> a EXTRACTION r AIR HAMMER-DRIVEN CASING THICKNESS SCk t40 TY==-OF CaSING p STEEL XPVC G JTH_R: <br /> a VAPOR 'kGUD ROTARY DEPTH OF CRC'J-- SEAL 1C)� TREMIE TYKE TO eE USED- GAUGERS ;KH;rSE <br /> p AIR SPARGE n PJSH PONT GROUT SEAL PUVPc: X^les p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING Q-1AND AUGER GP.CJT SPECIFICATIONS: AJM- CPltwu} &099 bea nate <br /> p OTFER: OTHER A=PRCX.BORING DE.�TH IM, _V3OLTED TRAFFIC BCX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?AG5 ('(YE3,lis:spe..flcaticrs he-e). 94ee w jowl sho e <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 applicati wand that the work will be done in accordance with San Joaquin <br /> County Ordi an ,R es and Regulatio , nd all applicable Callfornia S//tate Laws. <br /> Signed x TitelCompany <br /> Print Name P 1 USC Date IU l n 10l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / 101; <br /> Application Accepted By 7t.w� `'� Date Issued�(�i Aireal ""I"Ly is< t� <br /> Crout Inspectlon By Date Final Inspe-_:Ion By Date <br /> Destruction;rsoecticn 3y Date <br /> COMMENTS ICONDITION3 <br /> ACCOUNTING ONLY: AIDS# ` <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK tt REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �; 00� 1iI <br /> C-57 WC -WAIVFR C-57 Letter of Authorization to Sian pe.-mit Encroachment doc 9/27/00 <br />