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.< x: , <br /> WELL'ERMIT APPLICATION F�M <br /> 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 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 /> Assessor's <br /> WELL Location I a1Z�s(� L7• l-��1, 9 Cross Street u7000ekr p" City Ae!ty Zip 2r2z o Parcel# 0l7 -o9^o3G <br /> PROPERTY Owner_ttlea a*3 bid ddress M6 g" kmm� ACity 'Sf%czipqSV2i Phone#911.-383-1741& <br /> C-57 ContractorAddress b- cl[ 3 City`s.- iS Zip 5 y 57 f Lic# Phone# 707 <br /> Consultant/Sub Contractor PP. : BOWft R '•9. Addresses 2 3 Cja-Melo%% 0!City_ Loo I-N C-21'21%3_Lic# Phone# tog-31.9 -big 2. <br /> GIS Coordinates:X Y Township A Range 7E Section 3 t <br /> WORK TO BE PERFORMED: <br /> jjNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> JWSOIL BORING# =6 A AA' Q OVER-BORE <br /> a WELL# PRESSURE GROUT <br /> 'Other. GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> fi:MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?d YES Q NO WELL CASING DIA: <br /> a EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS UHOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: p Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') two <br /> %SOIL BORING a HAND AUGER GROUT SPECIFICATION <br /> 0 OTHER: Q OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINCpS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this tbplication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rul s and Regulations of the San Joaquin County. <br /> "CL THE UNIT IV INSPECT 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x L Title/Company `✓6 �/ <br /> Print Name Date l <br /> SITE MAP IN UNIT IV FI "DDRE=SSYORK PLAN DATED <br /> ENT E ONLY <br /> Application Accepted By Date IssuedArea <br /> Gout Inspection By Date Final Inspection By Date <br /> Destruction Inspection B Date <br /> COMMENTS/CONDITIONS: `Qlr - r - 19 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' tDATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 O `lb�3b <br /> C-57 WC/WAIN C-57 Letter of Authorize on to _Encroachment doc 7/17/00 <br />