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WELL PERMIT APPLICATION FURM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ORIGINAL <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 Joaqui County Public Health Services,Environmental Health Division. <br /> nn Thar n4An Pool) Assessor's 1 <br /> WELL Location i q-7'19 (,&()4--o(� P06Qross Street"P,io L ,,2 . City L O,0 i Zip Parcel# OSS' iSG - 2 Y� <br /> Di K f,4 . £c Uor Abu <br /> PROPERTY Owner T('AC y Address ��3 N. 5?remit City �Tr�K"'�!�Zip9 52o Z.-Phone# �04' 9 3 2^ /Q33f <br /> I Q M/ll'7i,�eZ 9Ys �- <br /> C-57 Contractor(/';I,�GC- DP-XL1,!A q_Address -% 91t 1w� 9(,� City Zip s3 Lic# Phone# 9 Z 5 <br /> Consultant/Sub Contractor r ` c' . Address9 C)Q S IV, LV r bW') City S7SX-0,/-tic#��022 Phone# Z,9 -)/p0 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFOR <br /> NEW WELL/BORIN (CPT, EOPROBE,HYDROPUNCHpHAND-AUQGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> IL BORING# P'1 n 4 r`(� . / Z- B OVER-BORE <br /> a ELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE c-I-I MULTIPLE CASINGS?BYES ONO WELL CASING DIA: ��� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N f&TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALT,4 aL PPi rf TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE '�'I'USH POINT GROUT SEAL PUMPED: 0 Yens B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING �/0 HAND AUGER GROUT SPECIFICATIONS:—)On f 1�- AW D C� M Irl � ^' <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 1 5o 4�tt 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE 5� <br /> CONDUCTOR CASING PROPOSED? N (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 California State Laws. c <br /> ��� Title/Company PR �C �' C55 <br /> Signed x <br /> Print Name ' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: N <br /> WORK PLAN DATED: 6 Y �p'O°• <br /> Date Issued Area Dom" <br /> Application Accepted By <br /> Grout Inspection By <br /> Date Final InspecLon �tj&Date�: <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 260 /c.p oD3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />