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I i <br /> co�o <br /> —.-J <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 o f V <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance with San <br /> Joaquin County Development Title Chapter 5-1115 3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> / P j Assesso s <br /> WELL Location X966 i is� ( PIE Cross Street o bd h kw 4 DC�ty L- Zip �SGdtl Parcel# fs-1- A70 -�I y <br /> PROPERTY Owner l,{ 7(0 Address 5 3o Ac Z 4aoty �Cft*r' Zip l�Phone# ov'7 `lS-)-6. 7 <br /> C-57 Contractor 1!V r l l [►1.L Address [/v a J��� Cih+ ef�'1 ZiP�s+^°Y�Liu# l��Gr Phone# Y16 777- 7�L <br /> Consultant/Sub Contractor VI►�nhNtwtPal 174JAG"s /&O-ox 0444! _iApty Ct�u r~L:c# C163y, Phone# �7 -��� <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# []OVER-BORE <br /> 0 WELL# lU- �i l� 0 PRESSURE GROUT <br /> "Other -'� T�Grout Specifications <br /> COMMENTS <br />� TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> *ONITORING HOLLOW STEM DIA OF BOREHOLE��MULTIPLE CASINGS YES �NNO WELL CASING DIA o+ <br /> 0 EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS SOW Yd TYPE OF CASING 0 STEEL *�VC 0 OTHER <br /> APOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED []AUGERS d HOSE <br /> R SPARGE 0 PUSH POINT GROUT SEAL PUMPED I(Ye p No (NOTE MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER 'OTHER APPROX BORING DEPTH q 5_/0 6 ABOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED'?_�d (if YES list spec:fica4ons 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 /> Signed x �jtvlorj(5 Title/Company �/YL/1r ✓1 N'i�,c L �C[ +� _ <br /> Pnnt Name B P"3'1-&- A r ty" _ Date V1310 0 <br /> DEPARTMENT USE ONLY T <br /> SITE MAP IN UNIT IV FILE,ADDRESS' 5&0 <br /> WORK PLAN DATED. <br /> Application Accepted By Date Issued Z� 7z —0 Area <br /> Grout Inspection 8y Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> COUNTING ONLY AID# FArtt <br /> "PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> R# d0 <br /> C-57 WC -WAIVER C-57 fetter of Authorization to sign permit Encroachment doc 9/27/00 <br />