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WELL PERMIT APPLICATION FO 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 Development Title,Chapter 9-1115.3 and the Standards of SanJoaquin County Public Health Services,Environmental Health Division. <br /> WELL Location I gzsG lU• ����+�9 Cross Street L�OOOAma -city /I-en!!V Zip ZS2 2 Assessors <br /> Parcel# OI? -09 ^034 <br /> PROPERTY Owner iA�lt►tts�•� f7���EC�ort wtLsAAddress C' '��'`�' City S Zips Phone#91.-.383 17470 <br /> C-57Contractor Address V-0- Z&V 3S4 CityP.jq,*c.6 Zip Lic# Phone# 7b7.39�^ <br /> 1 C-2t1tu <br /> Consukant/Sub Contractor'p•Y lal C L"R P ID. Address 47.1 City _Lic# Phone# <br /> GIS Coordinates:X Y ,Township A P Range 7E Section 3 f <br /> WORK TO BE PERFORMED: <br /> i(NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> RLSOIL BORING# &J A MW-1 0 OVER-BORE <br /> a WELL# 0 PRESSURE GROUT <br /> -Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> SMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL []PVC 0 OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS []HOSE <br /> []AIR SPARGE JCPUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Ff SOIL BORING 0 HAND AUGER GROUT SPECIFICATION <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORIN S REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby certify that I have prepared thisplication 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 /> *C L THE UNIT IV INSPECT 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x Title/CompanyJ �/` <br /> Print Name Date�is-l.. <br /> SITE MAP IN UNIT IV F�"DDRESS ,PORKPLAN DATED <br /> T U§E ONLY <br /> Application Accepted By j' Date Issued Area <br /> Grout Inspection By <br /> Date----' Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS t CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'P BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1z3 D <br /> C-57 WC/WAIN C-57 Letter of Authorize on to i permit Encroachment doc 7/17/00 <br />