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FILE COPY <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 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> Assessor's <br /> WELL Location2LZL) �d Cross Street 7T-e4,D/✓City TT Zip95 34G Parcel#Zf&-/3o-14�)' <br /> PROPERTY Own,,-_-Ie '°� 'rAddress�SG� !ieldiGo/�� City��Zip`j' 76 Phone#ZoZ,�7�-/ADD <br /> C57Contractor/A.L Yt' Address3Zz9�/ 9 Ci a-+' up Lic#S3�/�Phone#!°/G <br /> L .sdv9�tx� r✓1' <br /> Consultant/Sub Contractoc�/0?•/1wki;�f =Address �d CityLh+� ickPhone#9/� <br /> GIS Coordinates:X3-'+.1/6$V./ ,Y/Z/. �/Z5�8f//SJ,Township Z.5 Range Scf Section �3 <br /> WORK PE ED: <br /> []NEW W WELLLL ORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION(choose type below) <br /> SOIL BORING# /iG-S.B/r j'/02_ H OVER-BORE <br /> WELL# [I PRESSURE GROUT <br /> 'Other: Grout Specifcations: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING jrHOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES 0 NO WELL CASING DIA: <br /> U EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: flSTEEL I]PVCCU OTHER: <br /> a VAPOR H MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:no. UGERS HOSE <br /> H AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: a Yes o No (NOTE: MAXIMUM FREE- LL DEPTH IS 30') <br /> 'SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: /NE 7 <br /> []OTHER: []OTHER APPROX. BORING DEPTH []BOLTED TRAFFIC BOX or []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 /> <jWer certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ty O finances, Rules and Regulations, and all applicable California State Laws. <br /> Signed -�"�� <br /> Title/Company����� alJ�� � � <br /> Print Name S Date SIJ �/�Z <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 75 CU VCZK R� <br /> WORK PLAN DATED: D 3'oZ <br /> Date Issued Area <br /> Application Accepted <br /> By <br /> ?/ <br /> Grout Inspection By <br /> Oate Final Inspection Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE ' PERMIT/SERVICE REQUEST# INVOICE <br /> .�b. .5 3, oar s <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroochnneg-t doc_ 9/27/00 <br />