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i <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> �1�SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> J ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> JpQA304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> MAY 9 " <br /> P�ZN (209) 468-3449 TIAY 0 1 <br /> f��,,1 ,�'��`V "�FFq NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { <br /> Application is her? de 1SarL( Iagr�Fn`Counry for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Dev t i e,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> J� ��/ I/ Assessor's <br /> WELL Location ZW//11y Fh+CLwa AVC' >tOcR...1"al Cross Street t✓ouvt-I- C(U� City 51-oc-I�'MM Zip Parcel# <br /> PROPERTY Owner (�`tV oT S"l'oLlc..-tOy) Address 2500 K)owW 'Dr City s'roc.�.-ItY1 Zip Phone# 9K4 -8'722 <br /> C-57 Contractor F -[c,n EyNQtCQ1. 'Address ''S I,laca_City V,0O SV. Zip457-SZLic# frb 38G5Phone# �17 Z'35'70 <br /> Consultant/Sub Contractor P'Y 'L AS506atg5 Address III'7Lo&, Pdl relCity oG(.Csfnlic# Phone# 5-71-Z7?z4 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PE ED: <br /> NEW WELL/ ORIN (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type belq)y) <br /> SOIL BORING# SS l::j H OVER-BORE ' <br /> a WELL# �PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z-2-" MULTIPLE CASINGS?II YES 0 NO WELL CASING DIA: - <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING II STEEL O PVC Q OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL N P, TREMIE TYPE TO BE USED: 0 AUGERS H HOSE <br /> a AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: H Yes II No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )(SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: _f�C.h'I'^n,fn Grout- - <br /> p OTHER: Q OTHER APPROX.BORING DEPTH IS-2O BOLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (O (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/. <br /> Signed x L_N-�-'•`^^�� "OMS, <br /> Title/Company T� H SSoc-lo-tt s == C- <br /> U1z <br /> Print Name �2.o.Y�r�s— t'1OMS, --4 __ Date 6IL �OI <br /> DEPARTMENT USE ONLY P <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �• �• L& D to Issued • ZOO Area <br /> Grout 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# Wio <br /> DATE PERMIT/SERVICE REQUEST# INVOICE <br /> s O vol DI <br /> C-57_ WC=WAIVER_ C-57 Letter of Authoi n permit_Encroachment doc_ 9/27/00 <br />