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0 0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> JAN 2 3 2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> ENVIRONMENT HEAL(N 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <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 /> ,�( II /� _ Assessors <br /> WELL Locatlon 5� [ )jo"' bj-- Cross Stree� -'tr-a City YO Zip �-C�� Parcel#[K', <br /> PROPERTY Owner i,valb(' Address���7'R 6 l City-Zip Phone# <br /> /� rI � 445- <br /> C-57 Contracto —t ( Address1� ITOU/B Ciry_J"Iar-p¢� ip Lic# 16,' Phone# <z — ?zb <br /> •- t� �`i h <br /> Consultant/Sub ContractorrAddressc( IiPn-rc%v� " pCityZ,rTLic# Phone#660"�M'-o/IZ <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ESTRUCTION(choose type below) <br /> 0 SOIL BORING# >FQVER-BORE <br /> W ELL# YI.I.I� 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?BYES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ' OSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: 0 Yes %'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 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specificaflons 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 O di a ces, Rules and Regulations, and all applicable California State Laws. 1 <br /> Signed Title/Company�e� rS't' bSCr('"' L�'h'� <br /> Print <br /> DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:I/ <br /> Application Accepted By 4iLmy Date Issued /1131 b t- Area_eim ll tac <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> o9oz C6 - z(' A* 11 ZA <br /> C-57_ WCL--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />