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I <br /> I' x WELLERMIT APPLICATION FM .' SITE { <br /> h <br /> MITIGATION '. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTHDIVISION (PHS-EHD) <br /> 304 E. Weber, Third-Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Aapiicadon is hereby made to San Joaquin County fcr 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 Jcaquin County Public Health Services,Environmental Heaith Division. <br /> Assessor's <br /> i� WELL Location ZSO`f C. Ere mart+St 5fioc4�hiiCross Street"ri I V)Cr-i City-5't'oc e-t-oY1 Zip Parcei# <br /> PROPERTY Owner Disse l �u _Address Z$0� �.nFr c.1�v�f 5t City to Zip Phone# CfY(o-"OZ33 <br /> C-37 Contractor �ccl, CAV i roe j0e Z;;, _Address 3 ` r City �?-Ip 2 ,�-Lic#4 38GS PhoneK Z- <br /> Consultant!Sub Contractor. TC_ G Address City o s{'J Lic# Phone,-. 57?-ZZ'L( <br /> 'I <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL!BORING CPT, EOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type bel�yv) <br /> SOIL BORING# Z 0 0 PRESS BORE <br /> ORE <br /> 0 WELL# SURE GROUT � <br /> 'Other: Grout Specifications: <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE f.SS a MULTIPLE CASINGS? b YES "a NO WELL CASING DIA:� <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N Pr TYPE OF CASING: [ISTEEL O PVC 0 OTHER:_ <br /> []VAPOR 0 MUD ROTARY" DEPTH OF GROUT SEAL + % TREMIE.TYPE TO SE USED: GAUGERS WHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED:IAYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1j.L0--t C�±e SurLtgA,+-X- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,fist 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 TitielCompany <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued Arza <br /> Grout Inspection By Date Finai Inspection By Dat <br /> Destruction Inspection By Data <br /> a <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# ti r!u <br /> PE CODES FEE INFO ADAOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Encroachment doc 9/27/00 <br /> C-57 WC WAIVER <br /> C-57 Letter of Authorization to sign"permit <br />