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WELL PERMIT APPLICATION FL?RM SITE <br /> 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 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 D velopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> pI13 •f tilwr ft �-..�r�li� Assessor's �T <br /> WELL Location7Sr S ht'7-wr n! C- _Cross Street HG/L City I�TdG/<!'s�Zip Parcel# T <br /> PROPERTY Owner SA..L ?D.lQ H/h/ 49"*-' ddress AR/0 /AT�6N AqF,City j7A 41V11 Zip F /Phone# 6�-3aaD <br /> C-57 Contractor Gts«ot yr�LUnrl�Address 3672 O/111L !wK City /1- Zip f ic#77757O phone# Ya' 41r 7�W <br /> 77++ 3ai7 rcrcljo.GcJ� 04`6L'M <br /> Consultant/Sub Contractor �/G .F2 Lf Al. dress suraeCiry 4 W 11 1-ic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> tyNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') I]DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> WELL# 2 w`LLS H PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS>q <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES ,KNO WELL CASING DIA: <br /> []EXTRACTION ,[]`AIR HAMMER/DRIVEN CASING THICKNESS Sam yD TYPE OF CASING: []STEEL APVC []OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL'/Sr d'9O r TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: K'Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: We <br /> OTHER:—H OTHER APPROX.BORING DEPTH 70—� '9 /00 TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? .fid (if YES,list specifications here): <br /> 'COMMENTS: F-!✓ AY L T 7d� SD-7a <br /> aiVc G✓fi/iL- T > 1'eno /DD ScrLc�.<C <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 Ordiinnannces, uless nand Regulations, and all applicable California State Laws. <br /> Signed x !//s ��`Y�'7��/�eYP t^ Title/Company15��Ct <br /> Print Name GG lso�T //� J Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: t U a N !-F1 w <br /> WORK PLAN DATED: 2 I S Io Z I C', <br /> Application Accepted By Date Issued ZO 0—Area <br /> Grout Inspection By -yn c enA Date U al by Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cnrx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3so� .moo S-Zlc,2 InF b oZ sR# 3 0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />