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WELL PERMIT APPLICATION FORM SITE <br /> VA 5 1001 MITIGATION <br /> - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> p NMENTAL HEALTH DIVISION (PHS-EHD) <br /> 4 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 /> Assesso s <br /> � -0 �0 <br /> _ Cross Steeto�a�CitCCZip S Parcel# <br /> WELL LocatlonQi <br /> PROPERTY Owner It e -T&Ae. ar.. Address Y6 City. Q G <br /> 7jpgZK Phone#44�2rS i <br /> ` R� ty� ` per. — <br /> C-57Contractor d� r1 ' Address„ 5C ►BOWL 1 Ci r `Zi r_ Lic# 51 Phone# 5 �B <br /> Consultant I Sub Contractor V U. Address S Stn tj- �0J_City—61—Yi_ic# Phone o2L1 <br /> GIS Coordinates:X ,Y Township ane Section <br /> WORK TO BE PERFORMED: -i' <br /> EW WELL/BORING{CPT,GEOPROBE,HYDROPUNCH,HANG-AUGER,OTHER-) DE TR CTION(choose type below) <br /> ;$;SOIL BORING# FEB H PRESSURE GROUT <br /> [I WELL <br /> 2001 A <br /> 'Other: Grout Specificatio�}s <br /> COMMENTS: tlV V P1 UN ' I w <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING Q HOLLOW STEM DIA.OF BOREHOLE�2 MULTIPLE CASINGS?[]YES. a NO WELL CASING DIA: <br /> Q EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS_/NA TYPE OF CASING: a STEEL []PVC ©OTHER; <br /> -'rAPOR d MUD ROTARY DEPTH OF GROUT SEAL ERT{f0- TREMIE TYPE TO BE USED: ,HP��S ©HOSE. <br /> IR SPARGE APUSH POINT GROUT SEAL PUMPED: Q YesNo (NOTE: MAXIMUM FREE=FALL Dll=PTH IS 30') . <br /> OIL BORING HAND AUGER GROUT SPECIFICATIONS: y � r u Idn . Y' <br /> a OTHER: O OTHER APPROX. BORING DEPTri1�0 <br /> BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /1/�9- (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 antes, Rules an gulations, and all applicable California State Laws. 1 <br /> Signed x TillelCompany- S � r /S <br /> I IIPrint Name I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 06 S e tow, _ r <br /> Application Accepted By <br /> l vv Date Issued G(�(i L J �v r Area <br /> Grout Inspection Sy ­xw�i Date Final Inspection By pate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ;COUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# C-PyBy DATE PERMIT I SERVICE REQUEST# INVOICE_ <br /> 3s o ,o 35 3 of <br /> C-57 WC --WAIVER C-57 Letter of Autho ❑ 'on t sign permit Encroachment doc 9/27/00 <br />