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WELLTERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> xJ 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 9-1111I15.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Lotion , V\ �C. Cross Street Mt k+ City �1+ ➢ ei, Zip ' arcel#ors <br /> PROPERTY Owner , L4„"1Va _Address q l q-7 L,jIJ_J717>?4 City f Yam»^ Zip 9'S2-IS Phone# <br /> C-57 Contractor Address Cityf7i�(YSY3 Lic# Phone# ILS-313-5/i300 <br /> Consultant/Sub Contractor i —4�Add(ress ( j VCI1 City ,( Lic# (a&227 Phone# k{0 —1 00 to <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED, <br /> }ANEW WELL/BORINGCPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> SOIL BORING# GPT- ( o OVER-BORE <br /> o WELL# O PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING [I HOLLOW STEM DIA.OF BOREHOLE 7 MULTIPLE CASINGS?1]YES a NO WELL CASING DIA:_ <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS OA TYPE OF CASING: I)STEEL O PVC I]OTHER: <br /> o VAPOR []MUD ROTARY DEPTH OF GROUT SEAL ( 0 0 r TREMIE TYPE TO BE USED: -,AUGERS U HOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: $Yes 01 No (MOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Pn.r`�-Q{.w,� C-2 aria 1 4 <br /> ,$OTHER: C\r 11 OTHER APPROX.BORING DEPTHI nn� a BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? k)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 Ordinel�s,, R es and Regulations, and all applicable California State Laws. <br /> Signed `�,.UL._ Title/Companl( (Qk;n tg6R �w,eLA 1104-91t• <br /> Print Name ClAkik o �S Date (OILS 10 I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: rr1,'n_ c p� <br /> Application Accepted By FAYX cc& Date Issued l.i� 13/ y( Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACU <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35C( CP/ ,rdti I I ,, 2k <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign perrnit_Encroachment doc_ 9/27/00 <br />