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1 / i <br /> WELL PERMIT APPLICATION FORM SITE <br /> 4A:N JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> JAN 0 2 21 001 ENVIRONMENTAL HEALTH blVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRi�i'.;/;Er, T HEALTH (209) 468-3449 <br /> PERI'I1T'1;ER'4r'ES <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Son Joaquin County for a permit:o construct and/or install the work described. This appficatlon Is r lade in compliance with Sar <br /> 'loaqui-i County Cevelepment T dle,Chapter 5-1115.3 and tt.e Standards of San Joaquin County PunIc Hearth Services,Envirer rental'H.eal:h Division. <br /> (�7'\ n ) Assessors <br /> WELL Loeatlon_-lJU Ule--�Q I[.l,I Cress SLeet t Cin/ Lo�l Zp �11;Qt�q-[)s z3 <br /> PROPERTY Owner u'f w. �t11�nn Add ess LJ 3 L 2.-QLJ�e c1 City S�feko_j Zip Z19 Phone# <br /> C57 Contractor �`C.J Adrress Inn St S4, CIp. U/Lc#_]2�O P^cne#�916) <br /> Consultant J Sub Contractor I�rmpuj ;;'t ro Address llyymlb 1! si City�tg�(�_Lic» Phone# <br /> GIS Coorcinates:X_,_ Township Range Sector <br /> WORK TO BE PERFORMED: <br /> []NE01 WELL 1 ECRINS(CPT,GEOPP.OEE,HYDRCPUNCH,HAND-.AUGER,OTHER-) DESTRUCTION(choose rype below) <br /> []PL BORING�],9,� 0 C�R-BCRE <br /> R'%VELL tl //[/iC�/ RESSUR'=GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYP OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i <br /> SONITORING ^IOLLCW STEM DIA.OF BOR=HOLE hIULTIPLE CAS NGS7 0 Y_S Q NO VIELL CASING DIA: <br /> []EXTRACTION [;AIR HAMMER'DRIVEN CASING THICKNESS Salt qU TYPE OF CASING 0 STEEL F]-PVC Q OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GRCJT SEAL 2q / TREVIE TYz'E TO BE USED: GAUGERS p"insF <br /> 0AIR SPARGE 0 aUSH POINT GP.OJT SEALPUVPED: []Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROJT SPECIFICATIONS: �lu,tx sti�C f e...t,,-A <br /> 0 07)-ER: _[]OTHER A=PRCX.BORING DEPTH l�1�,5 0 30LTEC TRAFFIC BOX or 0 STOVE PIPE <br /> / CONDUCTOR CASING PROPOSED? ('f YES,lis:spe;;Tf ations here). <br /> 'CCMMENTS: ZC4 q �, '� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE t3111IT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby cReer'Zo <br /> hat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ond Regulations, a I applicable California State Laws. <br /> Signedx � / Title/Company t / / <br /> Print Name JClI/�/ (Gi?/!/L c/ Date 1 Z l2 IOb <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / <br /> Application Accepted By Dare Issued / (3/o J Area D <br /> Grout Inspection By Date ,Final Inspection By Date <br /> DestrLctien irsoecticn @y Date / <br /> COMMENTS ICONDITIONS. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT RENIITTED CHECK U REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57_ WC_WAIVER C-57 Letter of Authorization to sign pe-mit— Encroachment doc_ 9/27/00 <br />