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p r1l�.M D WELL- PERMIT APPLICATION F,.,RM SITE <br /> � Cll MITIGATION <br /> JAN 1 8 2002 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH_ 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 488-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE ` 17 .� <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 inion. <br /> lrA&> Tri- � Vq <br /> ZttZ� Assess s ( -' <br /> WELL Location Cross Street�C�44itY cZipg5^'� Parcel# <br /> r% a�od/tj le -tL- '/wl-) Phonefry B�3- 17 <br /> PROPE Owner(Q/ �� Address Wkc- ��' City Se- ZIP <br /> yep <br /> _ 7 <br /> C- Contracto Addres:�� City 'CLOG ZipLi�hon <br /> C Sub Contractor '4 Address 637 moi`- City--VyA6XkUc# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> O K TO BE PERFORM <br /> E WELL/BORING E ROBE,HYDROPUNVCH,HAN -AUGER,OTHER-) q DESTRUCTION(choose type below) <br /> OIL BORING# y( LdPi" q OVER-BORE <br /> q WI=LL# q PRESSURE GROUT <br /> *OtherGrout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> q MONITORING lI HOLLOW STEM DIA.OF BOREHOLE --2-/kv:: MULTIPLE CASINGS?q YES B NO WELL CASING DIA: <br /> q EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS - TYPE OF CASING: q STEEL PVC q OTHER <br /> VAPOR q MUD ROTARY DEPTH OF GROUT SEAL lam1 TREMIE TYPE TO BE USED: 1]AUGERS p HOSE <br /> U AIR SPARGE �USH POINT GROUT SEAL PUMPED: .Lj- es 11 No NOT : M�MU��L- AL1.DEPTH 3S 30') <br /> OIL BORING II HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: QTHE, APPROX.BORING DEPTH �S`� 7$ BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N/P _(if YES,list specifications here): <br /> 'COMMENTS: S� / - Gt" / ✓Q`s' `�- <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 1 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. J <br /> Signed x <br /> f `C, Title/Company A 6 i -Date <br /> Print Name "A/1 14 wµ-- LA S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: v ----------------- <br /> Application Accepted By Date Date <br /> Grout Inspection By Oate Final inspection By _. <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'0 BY DAT PERMIT/SERVICE REQUEST# INVOICE <br /> o 20 /Y o2 3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit___- Encroachment doc 9/27/00 <br />