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WELL PERMIT APPLICATION FORM SITE <br /> I ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton , CA., 95202 r <br /> f (209) 458-3449 T I L E c 7 V <br /> 47 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> 1I ` �1 ' - Assessoes <br /> WELL Location IS Ni n ppl7vyt-W., 7T� Cross St/rreet �a�' city S-)-(x, "v) rp 5.�oi Parce(# <br /> PROPERTY Owner &rand : UFvrk S Address 1 PO C ox 6OIbi CityYI Zip dol Phone#C�U`7) 9S6 -y�i0 <br /> C-57 Contractor f" Addres��� SVltc�.+ . 191r City ,Zip �/� /. Uc#G 22� Phone# 7 % -10,06qq <br /> Consultant / Sub Cont2ctor TT(�-- Address ? S 6A O Sydtyc. Ai oDlh'�.}���—Lic#Y�LPhane#j a � 7�C�6 <br /> GIS Coordinates: X , y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNC'`� HAND-AUGER, OTHER') 0 DESTRUC7ICN (choose type below) <br /> ;SOIL BORING # y 50,1 . 6 ' ' I') J h/S DOVER-BORE <br /> WELL # U PRESSURE GROUT <br /> 'Other" Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �J <br /> U MONITORING O HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DFA: <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNE55 � TYPE OF CASING: D STEEL O PVC OOTHER: <br /> U VAPOR O MUD ROTARY DEPTH OF OR SEAL/ I fe TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> U AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: U yes "a (NOTE: MAXIMUM FREE-FALL DEPTH 15 30')- <br /> �01L BORING II HAND AUGER GROUT SPECIFICATIONS: '2 ,, 7 � � & 7 � and '>' �i � rf//On S I Ld-// <br /> 0 OTHER: 0 OTHER APPROK BORING DEPTH "" O BGLTED TRAFFIC BOX ar 0 STOVE /PIPE <br /> CONDUCTOR CASING PROPOSED? /1y` ,l/I IQ+4.-' ( if YES, list specifications here):_�J✓-�._ <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin ces, Rules// a d Regulations, and all applicable California State Laws. <br />{ Title/Company_�J__ _ / — <br /> Signed <br /> Date <br /> Print Name >1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /`7it s e. S� <br /> WORK PLAN DATED: <br /> Application Accepted By r Date Issued � L --Area <br /> Grout Inspection By - Date D ' Final inspection 8y Date <br /> Destruction Inspection By Date <br /> COMMENTS T CONDITIONS: <br /> ACCOUNTING ONLY: AID# _ <br /> PE CODES FEES INFO AMOUNT REMITTED CHECK # REC'D BY OATS PERMIT / SERVICE REQUEST # INVOICE <br /> SRFF <br /> C-57_ W(;.-WAIVER. C-57 Letter of Authorization to sign permit k Encroachment doc_ 9/27/00 <br />