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WELL PERMIT APPLICATION FORM SITE <br /> J�, JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> JAN 0 2 200] ENVIRONMENTAL HEALTH bIVISION (PHS-EHD) <br /> UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/ ERV(rF.S 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 dascrlbed. This application Is rade in oompliance with Sar <br /> Joaquin County Development Title,Chapter 6-1115.3 and the Standa..ds of San Joaquin County Fub'Ic Health SeMces.Enviror rental Health Division. <br /> (�?'\ It <br /> I / Assessors <br /> WELL Locatlo1 q36 ''ViL-6, Zrl Cross Street It p �Clty Loll Z p _?,Xcet#Qy 9-CJS 23 <br /> PROPERTY Owner�,yrttn.� df.1 _Address( ZZ.�14j]GaG�_Cih Zip z! Phone <br /> C-57Contractory9('J / AcirressW6 �� S4, CItyTS(G-671k zv.n <br /> Consultant 1 Sub Contractor hrau-,Q 7t ro Address�]1y�N Si Cityfs• Liz# Phone;# <br /> GIS Coorcinates:X .-._ ,Y ,Township Range Settlor <br /> WORK TO BE PERFORMED_ <br /> []NEr!WELL I BORING(CP-,GEOPP.OBE,HYDROPUNCH.HAND-.AUGER,OTHER-) Zlr,ES71 RUCTION(choose type below) <br /> [I S91L BORING# a g�ja -E_RE <br /> [WELL# '27 GA / rRESSURE GROUT <br /> 'Other. Grout Specifications: .UFi7� �� <br /> COMMENTS: <br /> TYPE-OF W°LL INST LLATION CONSTRUCTION SPECIFICATIONS <br /> r� <br /> ONITORING ^IOLLCW STEM CIA.CF BOREHOLE_ MULTIPLE CAS NGS?0 YES (�NO WELL CASING DIA: <br /> 11 EXTRACTION C AIR HANIMER'ORIVEN CASING THICKNESS Scit qu TYPE OF CASING a STEEL VVC U 07HER: <br /> [I VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 2t{ � TREMIE TY='E TO BE USED, GAUGERS p H:1SE <br /> 0 AIR,SPARGE n PUSH POINT GROUT SEAL PUVPED: [I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GRCJT SPECIFICATIONS: �� �'rIt, f e..e,,_4 <br /> 0 OTF-ER: —0 CTHER A:IPRCX.BORING DE?TH qL.S 0 ROLTEC TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? f If YES,lis:speclflcations here). <br /> 'CCMMEN7S:44_�J26u/ "� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> C►,LL THE U-IT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify 31hat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin tea, nd Regulations, a [ applicable California State Laws. <br /> Signed x ����C Tite/Ccmpany t // <br /> Print Name �CC44( 61(/ea/ Date �Zl7rJCG4J <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED: t� <br /> Application Accepted EN Dare Issued / /-3/01 -__Area 0 / <br /> Grout Inspection By Date ,Final Inspection By Date <br /> Destn.ction;rspecticn By <br /> COMMENTS f CONDITIONS. i <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT/SERVICE REQUEST A INVOICE <br /> q� - 8 gG1 Olo C1� / 0 00� 7 v <br /> C-57_ WC_WAIVER_, C-57 Letter of Authorization to sign pe^mit_ Encroachment doc_ 9/27/00 <br />