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• <br /> Corp <br /> WELL PERMIT APPLICATION FORM 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 andlor install the work described. This application is made in compliance with San <br /> th <br /> Assessors <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standard San Joaquin County Public Health <br /> Services, <br /> Zips96'207 Parcel#al/�8�si/`tl_O/ <br /> j/5/ PAG/F/e 4velVr/E CrossStreetR�y /°oA Ciry 9149 C? <br /> WELL Location GOLLEL.E Zip Phone# gay-SD3S <br /> IF <br /> PROPERTY Owner�N-10Ay14/N DELTA_ -Address s'��E �S WEGG City <br /> bon 3�3^S90o <br /> N- 5/T(J Address 950 HOo✓E ACtIA city qtr/NCI1iP Qy�3Li� 7ir{ <br /> C-57 Contractor 6 RE44 � �-E,vT/' GOiSyBPhone# <br /> Consultant I Sub ContractorEN✓/RGNW-_Wr-rG '4v0/dress /000- OR' L.° Ls4 City PLA Lic# <br /> Y ,Township <br /> Range Section <br /> GIS Coordinates:X�— <br /> WORK TO BEP M It DESTRUCTION(choose type below) <br /> []OVER-BORE <br /> []NEW WELL/ ORIN CPTL SOIL BOR.Hg ROPUNCH.HAND-AUGER,OTHER-) L PRESSURE GROUT <br /> L WELL T•eEM�E is Or rE'��Y/'v.PriON <br /> /► Grout Specifications: <br /> *Other: ( D �7• �� ��y OCI n/ To L,GAoE <br /> COMMENTS / F,14 A <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATI MUS TIPLE CASINGS?I]YES []NO WELL CASING DIA:_ <br /> 0 MONITORING BHOLLOW STEM DIA.OF BOREHOLE <br /> TYPE OF CASING: g STEEL n PVC BOTHER:_HOSE <br /> []EXTRACTION []AIR HAMMERJDRIVEN DEPTHCASINGOF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS [] <br /> []VAPOR o MUD ROTARY <br /> BAIR SPARGE I]PUSH POINT GROUT SEAL PUMPED: Byes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS. <br /> APPROX.BORING DEPTH_—a BOLTED TRAFFIC BOX or []STOVE PIPE <br /> [] <br /> OTHER.0 OTHER if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED. <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 Ordirr�nces, Rules nd Regulations,and all applicable California State Laws. EN✓/�oNhE �G A✓o/r <br /> __ Tltie/Company P'eE3/DEM- <br /> Signed x `- /O 27 Z 0 <br /> /f Date <br /> STEVEN/y• <br /> Print Name DEPARTIM/ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 5"0 <br /> WORK PLAN DATED: C) /1/ F'�- <br /> Datelssued �l-'4-007 —Area _-.. <br /> Application Accepted By -- Date <br /> Date Final Inspection By <br /> Grout Inspection By Dale <br /> Destruction Inspection ByAL <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3 03554- 1^2• Gad 9/27/00 <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br />