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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> n 304 E. Weber, Third Floor,'Stockton, CA., 95202 <br /> (209) 468-3449 D <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j <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 Joaquin County Public Health Services,Environmental Health Division. <br /> 'Z..14 Z Assessor's <br /> WELL Location � I"o^towN , AVC. J-Ibl- ross Street (2aumnjuvcity S-torr--ravl Zip P.A Parcel# IZIIR030 <br /> PROPERTYOwner. Ci��r�r 5toc-�ON Address Z5-00 00.v4 DF. City5't'bck.�tnN Zip Phone# 944- 877,'2 <br /> l <br /> C-57 contractor FtSG�'EnV. Address 391 5h �5 PI y_L City V& Ie: S ipl525QLic#687d(. Phone#,Ot/772.-35'70 <br /> Consultant/Sub Ganimeter RTC.- ASsno ic. 5, Address CityOCIAUJ , Lic# Phone# 671-Z7Z-1 <br /> GIS Coordinates:X 'Y ,Township T I� Range RGE Section S <br /> WORK TO BE PERF0 MED: <br /> -RN WELL GRIN CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) H DESTRUCTION(choose type belcyy) <br /> ,jrSOILBORING# SBI`f –I$ . HOVER-BORE I <br /> I]WELL# H PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING n HOLLOW STEM DIA.OF BOREHOLE x Z° MULTIPLE CASINGS?H YES a NO WELL CASING DIA:_ <br /> H.EXTRACTION H AIR HAMMER/DRIVEN CASING THICKNESS MA TYPE OF CASING: H STEEL H PVC a OTHER: <br /> H VAPOR H MUD ROTARY DEPTH OF GROUT SEAL N A TREMIE TYPE TO BE USED: H AUGERS H HOSE <br /> H AIR SPARGEPUSH POINT GROUT SEAL PUMPED: H Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING HHAND AUGER GROUT SPECIFICATIONS -BBe.AtOA ,L GrOU+ <br /> H OTHER:_fl OTHER APPROX.BORING DEPTH I3 I H BOLTED TRAFFIC BOX or H 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 /> r <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.11 n 1 <br /> Signed t1t-nwn^"'— + Title/Company Prb-im'k Nr i'71 L {"-iSSOC.I o-�.t-S <br /> Print Name lJ -0-�h� I�10 1'�S+L�IU Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: :, <br /> l�?eo <br /> Application Accepted By r� Date Issued Area V <br /> Grout Inspection By ! DateFinal Inspection B Date I{ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: . .f AID# rArtt <br /> PEE CODES FEE INFO AMOUNT REMITTED CHECK# R C' Y DATE PERMIT/SERV OICE h <br /> J' U I 1 <br /> C-57_ WC---WAIVER— C-57 Letter of Auth I o sign permit_Encroachment doc_ 9/27/00 r <br />