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WELL PERMIT APPLICATION FJRM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (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 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 of San <br /> Joaquin County Public Health Services,Environmental Health 3D <br /> ivision. <br /> Iq 1�9 -1 Assessors <br /> WELL Location Cross Street W� pQCtv C �"l p �ZParcel# q3 ( <br /> 4 U <br /> PROPERTY OwnerAti0_9rTZjCVht <br /> Address KfIZ 0'S�I� � City- �4e �� zip j _Phone# <br /> C-57 Contractor ��e +- T lG(Z INI�tTAddre [Ci-tyl—C ziP Lic#- y� hone#�`� �`/�/�� h/�� <br /> Consultant/Sub Contractor A J Address L�31 SI�tL�?F-O'LitY�� Lic# Phone#= 7C7 7 /Cyj b <br /> GIS Coordinates:X 'Y Township Range Section <br /> W05K TO BE PERFORMED: <br /> W WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> -Wlrz: 11 SOIL BORING# 0 OVER-BORE <br /> [ ELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING �OLLOW STEM DIA.OF BOREHOLE TJX/MULTIPLE CASINGS? YES O WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 256 Y'feA­ TREMIE TYPE TO BE USED: ,,fl-)�UGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes ,g-No (NOTE: MAXII IUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: L� a b (�/ l r�` <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH /F5 7:7 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CAST P POSED? (if YES,list specifications 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 and Regulations, and all applicable CaliforniaStateLaws. <br /> Signed x Title/Company <br /> Print Name <br /> �.� ��� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3U3Z b. <br /> WORK PLAN DATED: 70b0z L <br /> Application Accepted Byidt�.lfDate Issued � Area <br /> Grout Inspection By Date_ Final Inspection By/S Date t0 1 �� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 61� a,47°7L <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />