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n WELLOERMIT APPLICATION FAM SITE <br /> REE r N D MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> JAN 2 3 ?&1IRONMENTAL HEALTH DIVISION (PHS-EHD <br /> ENVIRONMENT HEALTH 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 <br /> Services,E�nv�ironLme Environmental <br /> Health Division. <br /> Assessor's <br /> SCrossSlreel City X62— am <br /> 4xD <br /> WELL Location3a ps,-2 <br /> PROPERTYOwner - " Address Fp,Rox an <br /> City �T Zip I O Phone# <br /> _ LF SS tF#2S 3l -58[X� <br /> C-57 Contractor 7 - Dt-h I Address 9/l 1 462s Ci urTi Zi�� Lic# I Phone <br /> Consultant/Sub Contractor <br /> Address ICity _Lic# Phone# O - -O 12 <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) "l](choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> I� -- PRESSURE GROUT <br /> ELL# <br /> GROUT SPECIFICATION <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> q <br /> HOLE MULTIPLE CASINGS?n YES ' Nb WELL CASING DIA: <br /> �A40NITORING -HOLLOW STEM DIA.OF BORE <br /> EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS 4TYPE OF CASING: 0 STEEL )PVC 0 OTHER: <br /> n VAPOR G MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: GAUGERS '*OSE <br /> n AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: n Yes >vo (NOTE: M S MMUUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING G HAND AUGER GROUT SPECIFICATION o C 2 t"`2 B LTED TRAFFIC BOX or n STOVE PIPE <br /> n OTHER: G OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? 6 (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> 'CA THE UNIT V INSPECTOR 48 WORKING HRS IN ADVANCE F,,OR A REQUIRE D INSPECTIONS <br /> -�of ���lC��.("Y't Title/Company <br /> C eb-' <br /> Signed x <br /> Print N e Date <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued / L:5 02_ Area G✓f??�r� 3 <br /> Application Accepted By Date <br /> Grout Inspection By Date Final Inspection by <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC/WAIVER,_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 7/17/00 <br />