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i i./ <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ut"IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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 /> 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 3 u/LU (i o..r' r�ble,'4Vf,Cross Street city Q�Zip FS- Q� Parcel# <br /> PROPERTY Owner +hU/t <br /> . ►'fl•,/ Sc�ralAddress El P,iltl City Si act 1V,..ziplPhone#- 6If yt� <br /> {� <br /> C-57 Contractor Lu1�'ae.�yJC�p tib ddress fG �67( 33 6 --CibAkM kiS Zip9yn)Lic#�Phone# 3 <br /> H30rJ <br /> Consultant/Sub Contractor TC. kS SdGi4� Address II1-1 4 alert 1't� !#6 Ci _ S- Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) A-11STRUCTION(choose type belcyy) <br /> o SOIL BORING# Q OVER-BORE <br /> n WELL# AplMSSURGROUT <br /> •Other. Grout Specifications: n <br /> COMMENTS: ZIQ.Si�ti c►,�. ♦ 141'j-I- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �1 <br /> ONrrORING Q HOLLOW STEM DIA.OF BOREHOLE,S u MULTIPLE CASINGS?Q YES NO WELL CASING DIA.- <br /> atxrRAcTiON a AIR HAMMER/DRIVEN CASING THICKNESS soh c40 TYPE OF CASING: a STEEL VeVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 11 AUGERS a HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: [1 OTHER APPROX.BORING DEPTH GZ c 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> CountyOr a s, Rules and Regulations,and all applicable California State Laws. <br /> Signed x 1 ) c h Title/Company J y-G� (J;,e </rc� <br /> Print Na �]of.� -}C./�i,�4.. ___ Date/Q y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /� P1 <br /> Application Accepted By "V �`� Date Issued <J 3V T Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAQU <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D PY DATE PERMIT i SERVICE REQUEST# INVOICE <br /> 2 ��- al <br /> C-57 WC -WAIVER C-57 Letter of Autho iza to sign permit Encroachment doc 9/27/00 <br />