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ORIGINAL <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 T • �''`�/�0 <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 S� <br /> Joaquin County Development Title, Chapter 9-1115.3 andtheStandards of San Joaquin County Public Health Services, Environmental Health Division. <br /> � �/ Assessors <br /> WELL Locatiorn / X77 yy' 7"to ko .,<,r"' ,,,eQ µ vc Cross,Sttrreeett .611 uncles ,' ,� Acii�ty .S��n zip %��a(� �7 Parcel# �7 <br /> PROPERTY Owner L(/Vi u�ess 7L� Ny((�n4deen City, �� Zip /IdWIPhone# ' 9� <br /> jq <br /> C-57 Contractor Gree 'T ,,� 5 . } v Address G50 yc) ue QeK Ciityllurttn = Z 7ipy` SS3 Lic#6S_00 Phone# V2,5= 313 - �> <br /> Consultant / Sub ContractorAkaAccQ Cxn ��vircAmo4fAddress 837 56L� " City S! ,L' Ion Lic# &ED,1,�7 Phone# y� 7- /UUP' <br /> GIS Coordinates: X., y., Township Range Section <br /> W RK TO BE PERFORMED: <br /> EW WELL f BORING ( CPT, GEOPROBE, HYDROPUr�CH, HAND-AUGER, OTHER') D DESTRUCTION (choose type below) <br /> SOIL BORING # 0' - /,s _ O OVER-BORE <br /> WELL It 0 PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: S , z wa I lC £c tit of y 45S LLL E C Le <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA. OF BOREHOLE Z rA MULTIPLE CASINGS? BYES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL D PVC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /U7GT TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE R�tUSH POINT GROUT SEAL PUMPED: ,D'Yes D No p(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 00c+ I c.nX <br /> D OTHER:.O OTHER APPROX. BORING DEPTH IDD BOLTED TRAFFIC BOX or O 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 ces,®®Rules and Regulations, and all applicable California State Laws. <br /> Signed x ./c- - Title/Company �l hcn ,n.4 /r. / S9c <br /> Print NameCrh � ' l ( er- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD SS : <br /> WORK PLAN DATED : eAlloof 42W Zoo � Z �0 <br /> Application Accepted By Date Issued -O�wq/� ea06 9 <br /> Grout Inspection By Date Final Inspection By YYY�Y���=° 8 ate ' 444 ' 02 <br /> Destruction Inspection By Date <br /> i <br /> COMMENTS ICONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 350/ �B 89 ' i5z DOZE 8 <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/C <br />