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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 <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 5-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> C <br /> Assessor's <br /> Cross Street 1 �zJ75A S �Jri. City S�c1�To J Zip 9 52C.�Parcel# 136 -,2 _(6 <br /> HELL Locationl{0� N.S.,,,, 1 �F �J',^._�Z'C— � � <br /> NAv ,rpt Address \oZ Ola .�Qc-�,...ra- City_J�cc�To� zipC15zo�Phone#(2c ) `I(-3 `IciGc <br /> ?ROPERTYOwnar ��L��aQ� C5'1-'lac9Dy <br /> ,-57 Contractor d DC����nc _ Address 1lZD <br /> city\5kEav1 Zip45 Licit Phone#�4r� 77 A �� <br /> T ' 4b S,r�e., City �1oOc Zc,Lic# Phone# <br /> Consultan Sub Contractor��wc Ic `c-ct�a �] _Address I lO 1 rl — <br /> HTM <br /> GIS Coordinates:X 64 _,Y LI aO 15 55.0 ,Township � �� Range l��L= Section <br /> WORK TO BE PERFORMED: <br /> >r1VEW WELL/BORING(C GEOPROB HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> []SOIL BORING# �OVER-BORE <br /> n WELL; a PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS' S tz-t f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES []NO WELL CASING DIA: <br /> EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC []OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:, Q AUGERS 0 HOSE <br /> Q AIR SPARGE N PUSH POINT GROUT SEAL PUMPED: []Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> []SOIL BORING a HAND AUGER. GROUT SPECIFICATIONS: <br /> 07HER: 0 OTHER APPROX.BORING DEPTH aQ PA& 0 BOLTED TRAFFIC BOX or [1 STOVE PIPE <br /> C CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: Sczt :R A^) <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 Ordin , R les dRgulationns},, and all applicable California State Laws. <br /> Signed x '—"� TitlelCompany <br /> -) Date <br /> Print Name i��� V-QU.\\,n`A-��y <br /> DEPARTMENT US ONLY do p- 0 CM r <br /> > �� � jLo 1 � � S Ivo r��P��n . <br /> ft <br /> J �( � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: w i(( L Ss �Q�Q —�� �'(-f �� L (drlCt 122 l� <br /> WORK PLAN DATED: Jam/ <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By _ " ' DateFinal Inspection By Date <br /> Destruction Inspectio y Date �n <br /> COMMENTS I CONDITIONS: 51)13,Mj 375 <br /> 0 �/K <br /> ACCOUNTING ONLY: AID# v,l <br /> PE CODES FEE INFO AMOUNT REMITTED TCHECK# REC'D BY DATE PERMIT J SERVICE REQUEST# INVOICE <br /> �+� / t, 5 <br /> C 57_ WC -WA IVER_ C-57 Letter of Authorization to sign permit____Encroachment doc 9/27/00 <br /> 60 39ti6 'i00�� H1�I� EEbEB9b60Z 95 Ei iOeZ/8Z/ZD <br />