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_ WELL-PERMIT APPLICATION F%-jRSITE <br /> M <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) . UNIT 1V <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 9-9195.3 and the Standards of San Joaquin CountyPublic Heaith SerAces,Environmental Health Division, <br /> Assessor's <br /> WELL Location �7�0 k �1) �te,�e km ry"n, LL11LCmss Street City LO� 7.ip q Sj4 parcel# <br /> PROPERTY,Owne� �syt°t r.ur. Address City Zip Phone# <br /> C-57 Contractor Address � Ity Ti�-Uc# Phone# <br /> Consultant/Sett Contractor v� dress 3l 5 City Lic# pZPhone# �6���oo✓r <br /> GiS Coordinates:X .Y Township Range Section j <br /> WORK TO BE PERFORME <br /> ©_NEW WELL/BORING( GEOPROBE,HYOROPUNCH,.HAND-AUGER,OTHER*) []DESTRUCTION(choose type below) <br /> SOIL BORING# C�-C=�� [j OVER-BORE i <br /> n WELL# []PRESSURE GROUT <br /> `Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL.. INSTALLATION TYPE CONSTRUCTION SPECIFICA ONS <br /> [I MONITORING [I HOLLOW STEM . DIA.OF BOREHOLE i` MULTIPLE CASINGS?[]YES a NO WELL CASING DIA:NA <br /> II EXTRACTION 1]AIR HAMMERIDRIVEN CASING THICKNESS r TYPE OF CASING: I]STEEL fl PVC a OTHER: <br /> []VAPOR Il MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: KAUGERS a HOSE ! <br /> []AIR SPARGE BUSH POINT GROUT SEAL PUMPED: ;,RY _B No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: � <br /> 'OTHER: ` OTHER APPROX BORING DEPTH r []BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PR S D? ^(if YES,list specifications here): <br /> I <br /> 'COMMENTS- 1 11I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS INADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that they fork will be done in accordance with San Joaquin <br /> County Ordin c R es and Regulations,and all applicable Ca ifornia State Laws. <br /> Signed x N 9TiifelCom <br /> Print Name 1 Date l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By to Issued 7S 0 Area L.4n 'Q ' <br /> Grout Inspection By Date final inspection By Date, <br /> Destruction Inspection By Date p <br /> COMMENTS I CONDITIONS: <br /> FACCOLINTING ONLY: AID# <br /> i <br /> DES FEE INFO AMOUNTREMITTED CHECK* REC'D Sly DATE PERMIT/SERVICE REQUEST# INVOICE <br /> € <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />