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-10) Fy( <br /> -WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 140V 3 200 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> I ---. 1r--. i' -; r,�; <br /> , ;D04 E. Weber, Third Floor, Stockton, CA., 95202 Yr'EGrr <br /> (209) 468-3449 a <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 /> � t I _ Assessor's <br /> WELL Location I�0�� .(0�1 ! Cross Street :. ul; City -%�,4 o Zip t'1 I8 Parcel# 195''{0'CX1Z <br /> PROPERTY Owner A; 6-4tI`Pf+� dress /AA 6fsa A ^=r r�t+ �+`° City -14.F zip 15a5 O Phone# Me,- Z16-0-- <br /> Ad C-57 Contractor( milt 4h t�s1101ftq_ Address .�� 1'IOtalr �� City Zips is#7 SIr Phone# <br /> `d S" fs s <br /> 'I �y//� i Zzss�3 MI5)Ss�� �VtdZ- <br /> ConsultantlSubContractor i�aL���r- _I�YGH__ _Address ���'� �+o'�+ Gr. City uti(,n Llc# Phone# �r��� <br /> G18 Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYD PUNCH H ND-AUGER,OTHER`) 0 DESTRUCTION(choose.type below) <br /> WOOL BORING# '1 1� �� []OVER-BORE - <br /> []WELL# ll []PRESSURE GROUT <br /> *Other: Grout Specifications: &cif e+"r'► _ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING []HOLLOW STEM DIA.OF BOREHOLE ,Z It MULTIPLE CASINGS?[]YES X1f WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL n PVC []OTHER: <br /> []VAPOR <br /> []MUD ROTARY DEPTH OF GROUT SEAL At:n Zb TREMIE TYPE TO BE USED: []AUGERS p[]HOSE <br /> �j SPARGE f PUSH POINT GROUT SEAL PUMPED: []Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BUIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> /0501?- <br /> U OTHER: 'K,OTHERG`aQ'LW-, APPROX.BORING DEPTH '2-0 []BOLTED TRAFFIC BOX or []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 jj)avq prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyOrdinan es and Re ons, a all applicable California State aws. <br /> Signed x Title/Company 0 <br /> Print Name <br /> T Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 2-21-02— Area a�8 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> f OUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 5 o Ow- i �•',�-a� �g62 <br /> C-57 WC ✓ -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc ✓ 9/27/00 <br />