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nv <br /> ME-= <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH.UIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA.; 95202 orf— <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i 0004) <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 rth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Enviro me Assessor's tal lth Division. <br /> WELL Locatl,kn �%�b �Cross Street ." City » Zip <br /> Parcel# CcA�l�.. 1 <br /> / G <br /> � �—Phone# <br /> PROPERTY Owner f Address!f!/lJ N e% _City 7lrc• cry^ Zip _ <br /> 'G�'/X?r 3�6 City r�!Gr 3 Zip�`� 7 Lic# Z�eo�7Phone#x'7 <br /> C-57 Contractor L!/ "'/ r�IYh Address J <br /> Consultant!Sub Contractor �e' rn iJtr- Address ' t�cttlle- CiIY i�c;'Lic#S 1 Phone#S3P �GfrS4% <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type bel6w) <br /> NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER')BORING# OVERBORE <br /> SOIL <br /> WELL. <br /> WEL ¢ � ,40 PRESSURE GROUT <br /> Q #.�?fti' 7 dv� ' <br /> `Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t <br /> ,MONITORING HOLLOW STEM DIA.OF BOREHOLE. i)TCA MULTIPLE CASINGS?a YES gNO WELL CASING DIA: <br /> 1]EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS S''Ch yQ _TYPE{OF CASING: p STEEL )I'PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEALif'1� TREMIE TYPE TO BE USED; AUGERS Q HOSE <br /> I]AIR SPARGE 1]PUSH POINT GROUT SEAL_PUMPED--/+Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> o SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH1&;k �/(� --lB BOLTED TRAFFIC BOX or �STOVE P1PE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> t <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin pe , Rules and Regulations, and all applicable California State Laws. <br /> Signed x 7 Title/Company J <br /> Print Name G'�, .� ���PrfQ Date <br /> DEPARTMENT USE ONLY <br /> I, <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 11?A6 G° <br /> WORK PLAN DATED: <br /> Date Issued - Area <br /> Application Accepted By I <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date f () <br /> COMMENTS ICON DITIONS: ` ------- y <br /> f <br /> ACCOUNTING ONLY. AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D SYJ DATE PERMIT/SERVICE REQUEST# INVOICE <br /> DD 2580 <br /> C-57 WC -WAIVER .0-57 Letter of Authorization to sign permit Encroachment doc 9/27 <br />