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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 he`re`by madeto San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> oaquin County Development Title/,Chapter 9-1115.3 anjd the Standards of-San Joaquin County Public Health Services,EnvironmentalAssessor'sHealth <br /> Division. <br /> NELL Location 2-ySJEA5 ' P►'K �re"' Cross Street v�.t/ .���//4 // �itY Zip Parcel#/,3/"��-35 <br /> PROPERTY Owner ( 0 Ca�c paQ Address �� �O AN /7(/K tL°✓ City Zip Phone# p <br /> g5P f{f. I E P-P- CityMar ► ? Zip Cj'1 Lic# Phone# 7�1'?Jl3'�G1U <br /> C-57ConVactor��N: � ry�/l►?a Addrless� �� ��L -�^ ��_�,�,�� /� <br /> Consultant I Sub Contractor s j C,,--PA T&-k6dTc.$kddress� 4 e5f � �-.L City _Lic# Phone#?1}g13y'd�78 <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> <NEW WELL/BORING PT,GEOPROBE,HYDROPUNC HAND-AUGER,OTHER') OVER-BORE <br /> SOIL BORING# v PRESSURE GROUT <br /> 0 WELL# <br /> `Other: Grou ec�icaions: <br /> COMMENTS � e b rirt4s l 20 / brnhe �o $O� byn�� /�5 ti<o ZS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> DIA.OF <br /> MONITORING HOLLOW STEM BOREHOLE MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA: /J <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-st TYPE OF CASING: 0 STEEL 0 PVC OTHER: NDNC <br /> 0 VAPOR D <br /> MUD ROTARY DEPTH OF GROUT SEAL-M jp 61,4vXk TREMIE TYPE TO BE USED: D HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED:�es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> $SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: NE jf CEIb1E1►�T <br /> )C OTHER: PT 0 OTHER APPROX.BORING DEPTHIWJ1M 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_A/0 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 Ord[ es, ules and Regulations, and all applicable California State Laws. <br /> �. Title/Company Q�,IGL DY �Q <br /> Signed x___ <br /> l/G <br /> Print Name /v <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED' v <br /> Date Issued 20� Area <br /> Application Accepted By ` 3 Z� <br /> Grout Inspection By <br /> Date (96�inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# EC'D AY DATE PERMIT/SERVICE REQU ST# INVOICE <br /> © 3 b ?a <br /> C-57 WC -WAIVER C-57 Letter of Author zati t sign permit Encroachment doc 9/27/00 <br />