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WELLTERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT 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 /> �• 5+ <br /> 1 , 1 I Assessor's <br /> WELLLocation (/.meg�• G-f� �T . Cross Street wx&CA- Cityslyd.�.�' l.,_ZipQ CZ�I Parcel# <br /> PROPERTY Owner,l...I,N.;b-L ess - City STV�FfM Phone#2.04 Z31 If <br /> C-57 Contractor Address CityMa✓d-iusl. ZILic# Phone# 2nSS$00 <br /> Consultant/Sub Contractor ress M S�Aljy] VA City2SSQjU i 1 ic#a ja_Phone# Lh.'! -1006 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORME <br /> Ll <br /> 0 NEW WELL/BORING P ,GEOPROBE,HYDROPUNCH,HIANDf�US ,OTHER DESTRUCTION(choose type below) <br /> &SOIL BORING# Cp a <br /> I]OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS MA TYPE OF CASING: []STEEL 0PVC []OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL__�f n I TREMIE TYPE TO BE USED: 'DAUGERS 0 HOSE <br /> 0 AIR SPARGE &PUSH POINT GROUT SEAL PUMPED: 41 Yes []No ((NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING-� 0 HAND AUGER GROUT SPECIFICATIONS: QAp{Y pn (n o .`{• <br /> '^te' <br /> *OTHER:y�O OTHER APPROX.BORING DEPTH 'r )r BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifiwt,7 here): <br /> *COMMENTS: , ` ..-k110 0�4diI4 <br /> NOTE: OFFSIT#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 Ordi0 <br /> hpes\, R les and Regulations, and all applicable California State Laws. <br /> Signed x /�\ \J� Title/Comparry <br /> ` t7 nCn�IFico LSaAC➢���(1 •.�ti�.rn v.hr�tJl, <br /> Print Name ,7(12 �2� _ Date 1,0' ��QI <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Lnf <br /> Application Accepted By 1`;-�t-a A Date Issued S G Area <br /> Grout Inspection By Date Final Inspection B Date. <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Sol �f Sf�l c Sg� C.u"'` qptf <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />