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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 <br /> Fl or, Stockton, CA., 95202 <br /> 3 <br /> NON-REFUNDABLE PERMIT EXPIRE51 YEAR FROM DATE ISSUED <br /> comp <br /> Assessor's_� <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 Health <br /> h an <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Pub 's✓ServPsEnvironmental ce#alth Division. <br /> City <br /> kkaV .n Sit- Cross Street 66�_Ci ${� cl(o2 - 10 <br /> WELL Location P� �oy Sze �Lk1-�ti Zip- <br /> 4,4 <br /> ip fS L=l Phone# <br /> f1 t ll✓ab� Address Ciry�— <br /> PROPERTY Owner `-' LDS <br /> joy 33t City�i'J�"�` Zip `(�Lic# <br /> i-I2�Phane# 34-y} <br /> l.�J.�.)lusaud Address ,$-`�-T'Z-Zil <br /> C-57 Contractor � Ps t. �b City A��5� Lic# Phone#� <br /> l"5 Address I I I T t,o <br /> consultant/Sub Contractor Range��Section, <br /> Township�� <br /> GIS Coordinates:X��Y—� <br /> : <br /> DESTRUCTION O(hoose Oe below) <br /> WORK TO BE PERFORMED: :PRESSURE GROUT <br /> EW WELL/BORING(CPT6SOILL BORING# ROPUNCH,HAND-AUGcR,OTHE <br /> k*ELL# I Grout Specifications: <br /> *Other,. <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTIONSPECIFICATIONS ' O WELLCASINGOIA:Z <br /> TYPE OF �� DIA.OF BOREHOLE `D MULTIPLE CASINGS. :YES VC :OTHER: <br /> ft-MONITORING 'g'rAIR HAW STEM c(n -TYPE OF CASING: :STEEL '9'P <br /> :EXTRACTION :AIR HAMMER DRIVEN CASING THICKNESS 5 TREMIETYPETO BE USED: :AUGERS HOSE <br /> :MUD ROTARY DEPTH OF GROUT SE4L (� <br /> :VAPOR GROUT SEAL PUMPED: tomes :No (NOTE: MAXIMUM`FREE-FALL DEPTH IS 30') <br /> :AIR SPARGE :PUSH POINT ��,�,..I- <br /> HAND AUGER GROUT SPECIFICATIONS: OLTED TRAFFIC BOX or :STOVE PIPE <br /> :SOIL BORING APPROX.BORING DEPTH Its <br /> :OTHER:_—:OTHER�� CONDUCTOR CASING PROPOSED? (if YES,list specifications here):�� <br /> •COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PFOR ALL REQUIRED INSPECTIONS. <br /> 51 t <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> all applicable <br /> County Ordinances,Rules and Regulations, and California State Laws. <br /> Title/Company oto / <br /> Signed- <br /> 1�� Date <br /> Print Name V 1 16 A,., ,q.l( f 1 <br /> DEPARTMENT USE ONLY V <br /> +C' C-}cy <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Il 20 O I f 3 I CY Area dZy <br /> Date Issued 2 Z, p <br /> Olt, T Date <br /> Application Accepted By Date a Final Inspection By <br /> Grout inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> A ACCOUNTING ONLY: AID# PERMIT I SERVICE REQUEST# INVOIC <br /> REC'D BY DATE <br /> PE CODES FEE INFO AMOUNT REMITTED CHEI ' a 2 �3 0 <br /> 3501 �5 .00 IAS g�z7�oc <br /> C-57_ WC—WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />