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--j WELL PERMIT APPLICATION FORM SITE <br />{ MITIGATION <br /> APR 2 0 2004 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENViRui,jfvJL JT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PEnNi.1T/SERVICES (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 /> I: Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location.2/yy XoNT41R /➢✓E Cross Street Ctaa CityZip Parcel# <br /> PROPERTY Owner C/TY OF 5770cKTcd Address )-Scb 01J'l be City S�oc K;roJ Zip Phone#Jo99dr/,/9' 7- <br /> C-57 Contractor GJaes�w+K� Address P.D. (Sox .33Citypa VIS Z4 Zip9yC 7/ Lic#7m? 7 Phone#70737/ +/3 <br /> Consultant/Sub Contractor{)TG 4SToctAlEES Address///76odEPAt,w CityMoZ6'-ya Lic# PhonekaLO 7"22/ <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) $DESTRUCTION(choose type beIV) - <br /> ? 0 SOIL BORING# gVER-BORE <br /> 0 WELL# - HIPGROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: SEE G/oRK <br /> jj TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `. 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC ]]OTHER: <br /> 0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: flAUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER - GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> i <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 prepare .this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, les and ulations, and all applicable California State Laws. <br /> - Title/Company f17G /�S COG r ATES <br /> I Signed x - <br /> Print Name N/F .VES <br /> Date��� 5" <br /> j DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C A ////(hl� <br /> Date Issued_/!/'! I ZL{)7 Area <br /> Application Accepted By <br /> Inspection By Date Final Inspection By 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 I SERVICE REQUEST# INVOICE <br /> �50Z v sol 22DV- }23 <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho izat o to sign permit_Encroachment doc_ 9/27/00 <br />