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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> �� �� Assessor's <br /> WELL Location 4i//9 S A',sr/y ST Cross Street /YETAme City-,&7 eA Zip AF= Parcel# el/1- 04-.?.3 <br /> PROPERTY Owner QP(3 Y /Ni&(,,A#Address�//9 S. �il/A SMff City�,f,vT[C19—zip9.S33�Phone# .td9- GOy-y629 <br /> C-57 Contractor , Wtst 1-142 mc'r ( Address. _ City . _Zip ; Lic#f ._ phone# <br /> Consultant/Sub Contractor,&Vb&-Q IA&M /CFL'Ime. Address Svpl s I City SJJ"IPAi Lic# Phone#tlo7')/;i3 y-dS/1+ <br /> GIS Coordinates:X Y Township .� J Range d Section J <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') DESTRUCTION{choose type below) <br /> 0 SOIL BORING# '7'440S OVER-BORE <br /> 0 WELL# ,/ /�# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: Al-OA7- &AI A107 <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 Ordinances, Rule and Regulations, and all applicable California State Laws. <br /> Signed x / Title/Company !A •D�a �w2�+► AvoCo(r�f S, /AVc <br /> Print Name /f�J/C <br /> �� Nt L/N /�OYLt KPS Date 0«l.BE.2 00_ 3 <br /> � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By —Date Issued - <br /> ZWJ Area <br /> Grout Inspection By Date - Final Inspection y Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# C'D DATE PERMrr/SERVICE REQUEST# INVOICE <br /> Z •V � (D � J 9/27/00 <br /> c-7 IA/� lA/AT%/CD !'_�,7 I o++ar n-F A„thnr ntinn to Ginn ner it Fncroachment doc <br />