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0 <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 and/or install the work described This application is made in compliance with n <br /> Joaquin County Developmenq(:?C-1 <br /> tie Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> C fib+n Sf�7�n-- `i 5"�0 P� 1#°jobs-Ilio l <br /> WELL Location S 15 +C Cross Street City Zip <br /> PROPERTY Owner �t'!� -t. Address <br /> C -54'+�t- 'City G Zip Phone#apor4 -75 -�vj- <br /> C-57 Contractor 3-+! -y Address J Cdy-+-5l?t Zip 75�y Lit Phane#7�L� - fes/ <br /> f( '� d � + /ctc�,• Lit 6� Phone# l �el <br /> Consultant/Sub Contractor vI V W%0 Address sty <br /> GIS Coordinates X Y Township Range Sech°n <br />' WORK TO BE PERFORMED <br /> `{ NEW WELL I BORING(CPT GEOPROBE HYDROPUNCH,HAND-AUGER OTHER-) p DESTRUCTION(choose type below) <br /> a SOIL BOR G# p OVER-SORE <br /> IfWELL# - a PRESSURE;GROUT <br /> -Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r( <br /> MONITORING gHOLLOW STEM DIA OF 80REHOLE_ MULTIPLE CASINGS'} YES ONO W ELL CAS€NG D€A <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSi TYPE OF CASING! STEEL VC OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED O AUGERS 0 HOSE <br /> AIR SPARGE a PUSH POINT -GROUT SEAL PUMPED Y s Q No (NOTE MAXIMUM FREE-FALL DEPTH IS 34') <br /> o SOIL BORING n HAND AUGER GROUT SPECIFICAT€ONC Ke-ff-c�f t;2 <br /> o OTHER q OTHER APPROX BORING DEPTH '/0 9 4r —;(BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDI {if YES list specifications here) <br /> 'COMMENTS <br /> t 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 antes, Rules and Re ulatro s, and all applicable(C5aUornia State Laws f <br /> Signed x Title/Company lf�pz) <br /> nct�4 L �c <br /> Print Name t� O-'lC+ Date Qct / la I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� <br /> C& &-�— <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Z`?-�%� 011Area 0� •• , <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS <br /> CCOUNTING ONLY AID# <br /> -CODES FEE INFO AMOUNT REMETTED CHECK# REC'D BY DATE PERMIT I SERVICE REOUEST>x INVOICE <br /> _ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment dot 9/27/00 <br />