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0 0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> AJ <br /> , _ Assessors <br /> WELL Location C)(� 7 v #v E ,e.1� Cross Stretet.A-i'�,,�1 u!s—,'r CityG��j'ctNj Ziplo 1 i arcel# 16 Z-v 3—C 3 <br /> PROPERTY Owner ✓ 10V"-te �S c, w Address 5'Dl W. W+ e�41- Cityf - ter n Zip 17� hone# _ <br /> Il <br /> C-57 Contractor t ` Addressq'30 1-101,V P- 11d. Ci ( r i 14C Lic#1 dS Phone# <br /> 77 11 mac. <br /> Consultant/Sub Contractor r r - a I L <br /> Ti'ix i Gtr E'r.-t Address I l KL°ifrD�. Air-City Gol,rlexLic# Phone# S�: I <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ! <br /> `,�[v1ONITORING IOLLOW STEM DIA.OF BOREHOLE K MULTIPLE CASINGS?0 YES `'KO WELL CASING DIA: <br /> [O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL /)W"PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ~ ''I TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes g No (NOTE: MAXIM M FREE-FALL DEP HIS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: y� ft cage" ��� ' � r rC�f(yj r C <br /> a OTHER:_U OTHER APPROX.BORING DEPTH �[�r �>OLT D TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? L7i."�(if YES,list specifications 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 Ordina ces, Rules and Regulations, and all ap licable California State Laws. <br /> Signedx �� 'r'� TDr L7I->` l ' I ItVCCille/Company-It`O ICCT Yt�'(tkt ;S'r /�Icr"-( C [2le It - <br /> l <br /> Print Name 1 c-Sk h£� A `4"Y!f') I"-jj Date ���y1 0 r <br /> APARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: pp <br /> Application Accepted By ,iwt9'l� Date Issued / 40 Area[Y�IZWG�C/3' <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAre <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Z90 1 �:C>o-" iz 0'8 G $ <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />