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WELL PtRMIT APPLICATION FOFv-A SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ORIGINAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - <br /> �pplication 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 /> loaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ( � Lo Assessor's ,I <br /> HELL Location�JJ`"1 G.1 f IC�I[,�t"+ 5/��.� Cross Street ���p Citvp�Zi�r11: _Parcel# jol <br /> 3ROPERTYOwne CShkJo�i�0.WN tf-t'._1`.-A- �dress�� �v�7 0 � �itj�3 Ziy,��i honelP, <br /> -57 Contractort. A dresAV-b QJ L9 A. Ci�Zipl "�"rJ Lic# I0�hone# 5 ✓W <br /> '.onsultant/SubContractoyl�. ��1jAddress%1�1�{�QC(Q,{�1I�Cit) lz.Lic# Phone# tD('� <br /> 31S Coordinates:X ,Y Township Range Section <br /> NORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HA14D-AUGER,OTHER`) a DESTRUCTION(choose type below) <br /> -�001L BORING# OR-T-- -L Q OVER-BORE <br /> [J WELL# Q PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE I MULTIPLE CASINGS?a YES�NO WELL CASING DIA: <br /> a EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: U STEEL Q PVC Q OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ),04r-) TREMIE TYPE TO BE USED: [I AUGERS 3 OSE <br /> Q AIR SPARGE �USH POINT GROUT SEAL PUMPED:A'es p No (NOTE: M�AXIIMMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORIN [I HAND AUGER GROUT SPECIFICATIONS: <br /> I&THER: a OTHER APPROX.BORING DEPTH 119D 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?, 70 (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 I nce Rules a d Re ulations,and all applicable California State Laws. <br /> Signed /, 1A, <br /> Title/Compan��`�AO���-�- �— <br /> Print Name.► I" / �� Date <br /> � n L r 2 I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3- 34 E <br /> WORK PLAN DATED: <br /> ri t�ara6 Area <br /> L <br /> . �l.t Date Issued <br /> Application Accepted By Date <br /> Grout Inspection By Date Final Inspection B <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# Ger^tt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 50 '� 545-1 is d ! tc3 sR# 3,25 �f <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />