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WELL,,,.,ERMIT APPLICATION FO""A <br /> SITE <br /> y 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 FILE COPY <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 � Cross Street City Zip Parcel# • 4 <br /> �,, �(+/�- {� , 1 roan <br /> I oft <br /> PROPERTY Ownerc� J'VNW O.-��_C PAIAddeskb. a; Y 9 " � Ci n ip—►44Phone# b �.�(p7t�!jt <br /> C-57 Contracto '( V a� Add e 9k Cl?� C yM, Zip, is Phon� 1 'VC_ <br /> Consultant/Sub Contract dress 171 1 City�IQii --� Phon L(Ob <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BO NG# . . 0 OVER-BORE <br /> -WELL#7 {� Qt�1 �L 'S Ile'p 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )7MONITORING )IVFiOLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS?0 YES4NO WELL CASING DIA: <br /> 0 EXTRACTION •� 0 AIR HAMMER/DRIVEN CASING THICKNESS " TYPE OF CASING: 0 STEEL PVC []OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:'4-Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH OLTED 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Org4ances, Rules a egulations,and all applicable California State Laws. <br /> Sign Title/Compan `,/Ife `�1� C.��,a � WOO <br /> Print Name in Date k ou 10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: Z y d/ <br /> Application Accepted By Date Issued /A/L Area <br /> Grout Inspection By Date / :9 OL Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# carµ <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 2,Owl <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit._.,Encroachment doc 9/27/00 <br />