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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> Rx\ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 02 304 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 San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location (D Z5 Al San Z044Utbt Cross Street C e City Zip tlParcel# 13`l-OfoO-(�/ <br /> PROPERTY Owner�p, O CA leQA Address 3�o /. N/C)AgEk 5T City< Zip 9�7 Phone# <br /> Address � <br /> C-57 Contractor QZ Zi �Lic# Phone#p25-3/ <br /> 3-597r�0D/o <br /> Consultant/Sub Contractorcp;� &ATtChcddress19616k We4011 5je-TCityLic# Phone#W23V- <br /> GIS � <br /> Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> ,,)S-SOIL BORING# y 0 OVER-BORE <br /> 0 WELL# �gPRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS Te,,o, P /� x So t , wa,�sr7 G`�2�r azo ��a{�- � ���� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 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 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <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 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 Ordi es, ules and Regulations, and all applicable California State Laws. <br /> Signedx -F j. TidelCompany t! �P/ZS� er r�Lt n 1F <br /> Print Name Date V _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ` y <br /> Application Accepted By <br /> �i Date Issued 1 ( DO�Iea_ <br /> Grout Inspection By Date �ZFinal Inspection By Date <br /> #T <br /> Destruction Inspectlon By Date <br /> COMMENTS/CONDITIONS: <br /> .I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' ,BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# -7A <br /> C-57 WC -WAIVER_ C-57 Letter of Autho za t sign permit Encroachment doc 9/27/00 <br />