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73- <br /> WELL PERMIT APPLICATIO URM 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., 952 <br /> (209) 468-3449 <br /> i <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU <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 <br /> Health Division.n. <br /> Cos 'd —0 <br /> Zip S Parcel# <br /> Street CityCrA <br /> WELL Locatlon �3 <br /> ,7CitzipgPhone#/)� <br /> PROPE2TYOwner Address rI 7V Lic# -7 <br /> city n ZiP96 � S% <br /> C-57 Contractor Q Address <br /> n {{�1 �3"7 S�.,i�W I?a�Ci lLic#�Phane <br /> Consultant I Sub Contractor fv� A0,1P� Qa&U,__Address�, ty <br /> ff o ��, 2-27 <br /> Y Township i g.� r" ,Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED: F�B 2 mt3 TRUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q LM� <br /> []SOIL BORING# OVERBORE <br /> [I WELL1 p PRESSURE GROUT <br /> # E VI <br /> Grout Specifications: • .. �` <br /> "Other: . - . :;�•i;}�"Ffi;1^��+ , <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 10N1TORkNG iOLLOW STEM DIA OF BOREHOLE $I MULTIPLE CASINGS?n YES ,"0 WELL CASING DIA <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS • � _TYPE OF CASING: p STEEL Q PVC Q OTHER: <br /> 'APOR p MUD ROTARY DEPTH OF GROUT SEAL S` _TREMIE TYPE TO BE USED: ,AUGERS ©HOSE <br /> „AIR SPARGE p PUSH POINT. GROUT SEAL PUMPED: a Yesr�� No (NOTnE- M I UM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: To� <br /> a OTHER- d OTHER APPROX.BORING DEPTH � _ BOLTE❑TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?j�_(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 Ordinances, Rules a Regulations, and all applicable California State Laws. <br /> �(, Tiile/Company 0_- -11Signed z _ <br /> Print Name 1 Q✓1 ✓� Date -a 6— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: xe n <br /> Application Acceptea Date Issued ' `-V DO Area <br /> ' Date <br /> Grout Inspection Syn: Da Final Inspection 13y <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> • C <br /> nCCOUNTING ONLY: AID# <br /> P£CODES FEE INFO AMOUNT REMITTED CHECK# REC'D B DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC WAIVER C-57 Letter of Author atio sign permit Encroachment doc 9/27/00 <br /> h <br /> S <br />