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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 02 JlJil 19 Pi'i 1' 3a 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 Development Title,Chapter 9-1115..3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> /sLGG Ly/9� Z 4p Assessors <br /> ty per`* Parcel# o87-oYo-3� <br /> WELL Location �± �� Cross Street � Ci .�/�u`f��Zi <br /> PROPERTY Owner G/lfle X�7AYf�i{/ /UU Address --City­------------Zip Phone# <br /> C-57 Contractor �� y�ddress ��23 dis G �/tGGLOity�� ip4V-11ZLic#7/7J-/0Phone#06-�i.JB-112v <br /> Q ' 916 19�/oY <br /> Consultant/Sub Contractor ����L Address �/7 ��(�Ciry GLic# Phone# 4,C) <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> RK TO BE PERFORMED: <br /> WO <br /> NM IWELL <br /> /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> 0 SOIL BORING# p OVER-BORE <br /> []WELL# / 0 PRESSURE GROUT <br /> *Other: G out Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �yj OLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES XNO WELL CASING DIA: <br /> 0 EXTRACTION 0CR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL APVC H OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Y.-/ TREMIE TYPE TO BE USED: AUGERS []HOSE <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: )ih es No ( T�OMAXIMUf I FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS-:\ <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 76 0 BOLTED TRAFFIC BOX or H STOVE PIPE <br /> CONDUCTOR CASIN PROPOSED? (if YES,list specifications here):—/-- <br /> •COMMENTS: Gf� jb' 7TJ �Sa"/ SCKeI�s-��l <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 Ordinances Rules and Regulations, and all applicable California State Laws. <br /> Signed x�� �� Title/Company Sfcr✓L G�fTGLl/fTj04l/j� <br /> Print Name G'L%/ys?--_L�>-'� -�"� S Date .6r- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 2- L o <br /> Application Accepted By Date Issued 11 2-C) D Area <br /> Grout Inspection By unA..Gv� Date 4ZJ 6-` Final Inspection By Date 2S 6z., <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cerw <br /> 1PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3TD � �°I-oma 1Sz663`I i oZ SR# 30a <br /> C-57_ WC--WAIVER--- C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />