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WELL PERMIT APPLICATION FORM SITE MITIGATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 304 E. Weber, Third Floor, Stockton, CA., 95202 FILE rL COPY 468-3449 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3nand the Standardsr0 S?n4.^Qui-County Public Health Services,EnvironmenAssesso Assessor'sDivision. Ra-ja-ross Street off city L OAi zip9 4a Parcel# r15S' 150 ' ZAP WELL Location EL DorA4ra Lc4- 932 03, Lo01 GH �T�ACvf�F • Address -713 N• s re«City STx.R'�l�Zip�152o7.-Phone# PROPERTY Owner M/lf 7iTeL 9YS 2 3/ aO /^ G 'LLcA `) 1-1 RnAO city rp s3 U�# anone# 9 5 - 3Sis C-57 Contractor DRt °1 Address a`^� 6goZ27 pp N, W boo) cityS7stKmn;c# Phone# �vrl yb-2 Consultant/Sub Contractor 71 , 6 • �--- Address 40I1S w Section GIS Coordinates:X •Y Township Range W RK TO BE PERFOR ❑DESTRUCTION(choose type below) NEW WELL/BORIN (CPT, EOPROBE•HYD PUNCH HAND-A GER.OTHER') ❑OVER-BORE IL BORING# '1 O �O ❑PRESSURE GROUT ❑ ELL# GrCCout Specifications: *Other: jL _ r r COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS� MULTIPLE CASINGS?❑YES ❑NO WELL CASING DIA: N/A ❑MONITORING ❑HOLLOW STEM DIA.OF THICKNBOREHOLE g a T,PE OF CASING: ❑STEEL ❑PVC ❑OTHER: ❑EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS 1-�1-- ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAI]jj4-&L—&-PLd TREMIE TYPE TO BE USED: ,AUGERS ❑HOSE ❑AIR SPARGE --jiLPUSH POINT GROUT SEAL PUMPED: ❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') /r �` l� CFmtm� SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS: 'r n f TLAr.r D ❑OTHER: ❑OTHER APPROX.BORING DEPTH 150 4-ES —❑BOLTED TRAFFIC BOX or ❑STOVE PIPE CONDUCTOR CASING PROPOSED? 11 / (if YES,list specifications here): *COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Or Inapces, Rules and Regulations, and all applicable California State Laws. A, -c—T GEP Signed x Title/Company_ , �Date 0I-05 -0 ) Print Name DEPARTM�EJNT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 6 9/p•oo. WORK PLAN DATED: Z� Application Accepted By Date Issued Area CIL OAB �+�-d— Grout Inspection By Date Final Inspectlon By Date Destruction Inspection By Date COMMENTS/CONDITIONS: ACCOUNTINGONLY: AID# PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE 35o i /-SD/ Z 003 C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00