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SITE <br /> WELL PERMIT APPLICATION FAM 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 County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> App y ry Assessors <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San <br /> nJoaquin County Public Services,EnvironmentalPI#alth Division. <br /> —7 }- Cross Street 0r:0 1\ City <br /> WELL Location I L d / C--, M G o� -7 / C.ity S c/C Zip��y�Phone# <br /> ,___Address 2� b �q � <br /> PROPERTY Owner p /c`($�l Lic#7J �7 Phone# G <br /> 90 R n( 33 b city o 1 Zi <br /> ddress Phonet( <br /> C-57 Contractor L i �/�,7 L P � Lic# <br /> .� �lly., vt Ciry/�,� <br /> �' '4� rrr^ Section <br /> Consultant I Sub Contractor Ad ress <br /> Township_�Range <br /> GIS Coordinates:X�'Y�� <br /> oose type <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(OVER-OVER-BORE <br /> CVNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U PRESSURE GROUT <br /> U SOIL BORING# <br /> gyWELL# -r-A)�TAr; Grout Specifications: <br /> 'Other: <br /> Comm 33//''.. <br /> CONSTRUCTION SPECIFICATIONS ES NO WELL CASING DIA: <br /> TYPE OF WELL INSTALL� DIA.OF BOREHOLE MULTIPLE CASINGS. VC OTHER: <br /> - <br /> 0 MONITORING 0 AIR HOW STEM TYPE OF CASING: U STEEL G F 0 <br /> AIR HAMMER/DRIVEN CASING THICKNESS S� TREMIE TYPE TO BE USED: 4kkGGERS HOSE <br /> U EXTRACTION DEPTH OF GROUT SEAL 6�--- <br /> VAPOR 0 MUD ROTARY <br /> 0 AIR SPARGE a PUSH POINT <br /> GROUT SEAL PUMPED: ,8A'es ONo (NOTE: MAXIMUM FREE-FALL DEPTH <br /> HAND AUGER GROUT SPECIFICATIONS: / <br /> 0 SOIL BORING � ,8-BELTED TRAFFIC BOX or a STOV <br /> APPROX.BORING DEPTH I� �r <br /> ,,j-OTHER:G3 r^It cfin�OTHER if YES,list specifications here):�� <br /> CONDUCTOR CASING PROPOSED. / i_ <br /> 'COMMENTS: <br /> 777NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. = <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONTCF <br /> cordance with San Joaquin <br /> I hereby certify that I have prepared this application and that the work will be done in ac <br /> County Ordinnaances,/Rules nd Regulations, and all applicable California State Laws.FJ�� G r <br /> U Tide/Companyray <br /> Signed z Date_ <br /> Print <br /> l IZt- l <br /> Print Name ��� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Area <br /> Date Issued t 0 <br /> C,% Date --,- <br /> Application Accepted By I 1A ra�1 Date Final Inspection By �—�/ jj <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMMtOUNT REMITTED CHECK# I zR O -3101-4- <br /> .-W <br /> 35-01 .0d $}S9/27/C <br /> C-57_ WC=WAIVER_ C-57 Letter at Authorization to sign permit_ Encroachment doc_ <br />