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WELL PERMIT APPLICATION FORM SITE <br /> - MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH [31VISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Coui y for a permit to constrvd and/or install the wcN described. This application Is r jade in compliance with Sar <br /> ,'oaquin County Cevelopment Title,Chapter 6-1115.3 and tY.e Standa•ds of San Joaauln County Pub'Jc Hearth Services,Enviror rental Health Division. <br /> //. Assessors <br /> WELL Locatlo•t"6S�Swt writ L�. br.Mr/ N(a.Cross SL oet Lci/,{�{yprws L.v City S� - Z _Parcem <br /> PROP=RTYOwn=r .Si", Address—3L6 Il,. C;N S4nr_L C*A 1p Phor,&# Q31'g3�4 <br /> C-57 Contrac!orT& Adcress 2365! I4' w6 LN"Dl Clry Trpc.SIZZbY P^orx qhs $��rl,,Z <br /> Consulant;SubCcntrctor6 2nr�rl aCU Address�ILI UAftfvS+reV_+ GtyFSCAo6. Li:z Phcne# fA-f 61r _. <br /> GIS Coorcinates:X " Township Range Secttr <br /> WORK TO BE PERFORVED:_ <br /> 0 NEW WELL r ECRINC I CP-.GEO?P.OBE,HYDROPUNCH.I-AND-AUGER,OTHER') `�CES71RUCT10%(c,�.00se type below) <br /> f]SOIL BORING' ! ` 0 OVER-BORE <br /> VVEL L a wWt "X''i•R`_SSURE GROUT <br /> 'CCher. Grcu;Specifi:abons:1W <br /> COMMENTS: D W LrvP D ir►�D'v- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING e''OLLCW STEM CIA.OF90R=H0'G MULTIPLE CAS NGS?0 YES 0 NO WELL CASING DIA: <br /> 0 E.XT"rAC TION E AIR HAAIMER'DRIVEN CASING THICKVESS TYPE OF CASING 0 STE=L 0 PVC G 0TH=Fl: <br /> n VAPOR E MILD ROTARY DEPTH OF G;;CJT SEAL TR=MIE-YzE TO BE USED: GAUGERS 0 H,iSE <br /> p AIR.SPARGE n et1SH PONT GP.OJT SEAL PUti'PED: Byes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORiNG 0 -iAND AUGER GROJT SPECIFICATIONS: <br /> 0 OTl-ER: CTH'cR A=PRCX.BORING DE---77H 0?OLTEC TRAFFIC BOX or 0 570'J=PIPE <br /> CONCUCTOR CASING PROPOSED? ( LYES,lis:spez.ficatiers here). _ <br /> 'CCMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNf T 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 Ord' an a, les and Regulations, and all applicable Callfornia State Laws. / <br /> Signed x / Tit elCcmpany < <br /> Print Name Date G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED//: <br /> Application Acceptec By �9e//,, <br /> �z:d Dare Issued eo Area �r Z <br /> Croat Inspectlon By Date Firal Inspe::lon By Cate <br /> Destruction;rspecticn 3y Date <br /> COMMENTS f CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: I AIC' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST A INVOICE <br /> �o' lit l 02-z lam' u of 00 3B 3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign pe^mit_ Encroachment doc_ _ 9/27/03 <br />