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WELL PERMIT APPLICATION FORM S <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'I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Countyfor a permit to construct San J install the work described. This application is moth Division.with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public H��e�allL�h�,ServZ Ps,EnvironmentalMce Health Division. <br /> 4a-7 S C, �� n •Cross Stree4y 'q Aye• City��-^it�- 7,�'y-�° 'I� <br /> WELL Location r- c0 '(ry, Zip�L=Phone#4k� rd <br /> /� Po 6)ox /n 0 City— <br /> PROPERTY Owner— G o' Address— # gy t6�Phane#cf /j-5`$OD <br /> -�c .1 i l Address Phone# 9-c9'S7Q-2� ) <br /> C-57 Contractor �'/yV ,- citylIlL Lic# <br /> , Address ��17 LOn c!'a r'^F *i•—'�CityrrL��-Lri' <br /> Consultant/Sub Contractor Section <br /> X <br /> GIS Coordinates: �=Y.,Township_ Range_�— <br /> WORK To BE PERFORMED: DESTRUCTION(choose type beloy+) <br /> OVER-BORE <br /> 4}.MEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER 0 PRESSURE GROUT <br /> 0 SOIL BORING# 1 <br /> 41-W ELL# H z � -- rout Specifications: <br /> 'Other: <br /> COMMENTS: ^1 <br /> TYPE OF WELL INSTALLATIONTYPE CONSTRUCTION SPECIFICAT MULTIPLE CASINGS?0 YES .$KO WELL CASING DIA:d <br /> LLOW STEM DIA.OF BOREHOLE <br /> 4I.A4eNITORING LBS G TYPE OF CASING: O STEEL 4.PVC 0 OTHER: <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �- <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes o No (NOTE: MAXIMUM FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Ole <br /> TED TRAFFIC BOX or 0 STOVEPIPE <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH �z_ yam$ <br /> CONDUCTOR CASING PROPOSED?/�O _(if YES,list specifications here): <br /> I ell <br /> 'COMMENTS: S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROAC <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTI S. <br /> I hereby certify that I have prepared this application and <br /> l�a t the <br /> work <br /> n ill be done in Laws, accordance with San Joaquin <br /> County Or inances,-tile an Regulations, and all app <br /> Title/Company <br /> Signed z Date 3 Z <br /> Print Name _. <br /> DEPARTMENT USE ONLY C <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: I I i 3,D ci, <br /> Date Issued if ./ Date_ <br /> Application Accepted By Date `� Final Inspection By (-- <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 4 0 7, --+ t D-4' <br /> .vo �65fA g9/27/01 <br /> &50 ( <br /> C-57_ WC—WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />