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F <br /> WELL PERMIT APPLICATION FORM S E <br /> 'L,�= - MITIGATION <br /> fr _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> -;V 3 Q 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 VA� , <br /> (209),468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f� <br /> San Joaquin County for permit to construct and/or install the work described. This application is made in coTnpliance with San <br /> Application is hereby made to q h+ <br /> Joaquin County Development Title,Chapter 9-1115.3 and th;e Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> I ,t1.�a� ��ppF��.,,.., 1 l Assessor's 7 <br /> WELL Locations-� �`' I1°", S treet �" LWiSwCity ut r a Zip 953rD Parcel# _�q$w�l �3 <br /> V t1'(-, <br /> PROPERTY Owner Ctelt I-A 5i!Zv3-. i Address_a 'S—,F2,1 LAI- <br /> AI- Zip 6'Xtt 0 lahone# <br /> L,e45�k IJ,u1 rd I 0; i <br /> _ <br /> C-57 Contractor rr� ra C�rf]��n,t Address gS`� City X iv!rZZip��s3 Lic# 4SIa`�hon � 311`4603 <br /> Consultant/Sub Contractor_�cl V " �yG� rvrc. Address � E Cres, 0 95 Clry D tri tic# Phone# '221 �IT <br /> t`; Aj rf <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDRgy NCl I NAGR,OTHER') DESTRUCTION[]OVER-BORE type below) ' <br /> SOIL BORING# <br /> - / 1 PRESSURE GROUT <br /> [] ELL# <br /> 'Other: Grout Specifications: �� [ Y►rnx°�rto''' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE Z t MULTIPLE CASINGS?R YES n NO WELL CASING DIA: <br /> []EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL n PVC []OTHER: _ <br /> MUD ROTARY DEPTH OF GROUT SEAL_8 �TREMIE TYPE TO BE USED: []AUGERS _;[];HOSE <br /> [] cr SPARGE `PUSH POINT GROUT SEAL PUMPED: 4 Yes []No (N TE: MAXIMUM FREE-FALL DEPTH It 30) <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> []OTH1=R: OT CONDUCTOR <br /> APPROX.BORING DEPTH A' P r []BOLTED TRAFFIC BOX or D 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 /> County Ordinan u es and ulatio , and all applicable California i Laws. Q <br /> Title/Company T� <br /> Signed <br /> Print Name �7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �� b0 �• �� <br /> WORK PLAN DATED: /S O/ <br /> Date Issued 2—20 Z Area <br /> Application Accepted By <br /> Date Final Inspection By Date_ <br /> Grout inspection Accepted <br /> Destruction Inspection By Date <br /> CC;"MENTS/CONDITIONS: <br /> Ac COUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECd��FA <br /> REC'D BYDATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 � <br /> C-57 V WC -WAIVER ,C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />