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WELL PERMIT APPLICATION FORM S1 <br />' MITIGATION ASAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT M1TiGA <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />' 304 E Weber, Third Floor, Stockton, CA,, 95202 O�� <br /> (209) 468-3449 G'o5�/QOl.J <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 DevelopmenTitle Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> s i f r f Assessor's <br /> WELL Location�6a ro P�Cr rr�rtC rr-p- Cross Street ohin, 6o City S�z:lin C�..._Zip��Parc-el# C c <br /> PROPERTY Owner t Q T ��C Address q�S/1/ j5r 90rctju City s��{t ISM Zip Phone# ! !3 7iE�E33 <br /> C-57 Contractor t'I �}K Address" !(N S S C, lP 'o-�zi- 56 L�c �hone#916 7 0-� <br /> Consultant!Sub Contractor f*riv0-urrrnea a Address A ?l ��'� Y jty kCeA `Lscat/� Y Phone#7l ) Uu- 1191 <br /> GIS Coordinates X 'Y Township Range Section <br />' WORK TO BE PERFORMED <br /> ilLEIN WELL/BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) []DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-SORE <br /> WELL# - ~1� D PRESSURE GROUT <br />' 'Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r <br />' ;MONITORING 'HOLLOW STEM DIA OF BOREHOLEJ;Z-10 MULTIPLE CASINGS-17YES 0 NO WELL CASING OIA e} <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SchA 10 TYPE OF CASING 0 STEEL XPVC 0 OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALrcf- S?/ _TREMIE TYPE TO BE USED 0 AUGERS. a HOSE <br /> IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED ' Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �E'�"" e <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH )&BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED7.D _(if YES list specifications here) <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 O Inances, Rules and Regulations and all applicable California State Laws <br /> ! Lr <br /> Signed x t Ea t Title/Company y[ U ryw ul M_-O <br /> rr ?? ��11 " <br />' Print Name �i~v! Date_�Q�r✓�J V _ <br /> DEPARTMENT USE ONLY !! <br /> SITE MAP IN UNIT IV FILE,ADDRESS '540 U <br /> WORK PLAN DATED. Z <br /> 4-ra-, Date Issued l'-o-0/ A-eaApplication Accepted By -- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destrucbon Inspection By Date <br /> COMMENTS/CONDITIONS Cos �� ^D <br /> CCOUNTING ONLY AID# <br /> 1 PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3�0 - 7, 3SRO �rJ ZSz� <br /> C-57 WC --WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_e!!` 9/27/00 <br />