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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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location q 7 y 7 U&51 LN- cross Street-4 /n tv/S S 1- City 5-'1�(X0.1 zip IS do I Parcel# /f7 1 33V0-fy <br /> 4(pl7 Cc,H.,n <br /> 6t,ev - &0" � NCity <br /> PROPERTY Owner � UryCSlur l?a w,a� Zip`t rlS Phone# 7di=8YJ-4F>Sf <br /> C-57Contractor (futc.je )�<11/,,,4Address 3 - ;a OMcC CCity .H: 4,,1 Zip`f- ) Lic#?17SIO Phone#'7/6'E 3Y- <br /> Consultant/Sub <br /> 5'Consultant/Sub Contractor S G0f�� Address3c/?��1T:,�c X1.2(,2 CitLic# Phone# H/GO`J0''� <br /> GIS Coordinates:X ,Y ,Township_ Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> ROVER-BORE 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) oseBORE <br /> 0 SOIL BORING# PRESSURE GROUT <br /> WELL It <br /> *Other: <br /> Grout Specifications: A'-'(I <br /> COMMENTS 2c5 , v <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS? YES Jf NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S<L D TYPE OF CASING: 0 STEEL ffPVC 0 OTHER: <br /> g VAPOR g MUD ROTARY DEPTH OF GROUT SEAL y 0 TREMIE TYPE TO BE USED: 0 AUGERS g HOSE <br /> a AIR SPARGE aPUSH POINT GROUT SEAL PUMPED: -g Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:—/I/ell I < <" /v' f <br /> R OTHER: g OTHER APPROX.BORING DEPTH 60 J g BOLTED TRAFFIC BOX or g STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Al (if YES,list specifications here): <br /> *COMMENTS: M tiV f M v/ M W w I I h A �' 'I- O V N�• <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, <br /> Rules <br /> /Jand Regulations, and all applicable California State Laws. <br /> Signed x Title/Company / c0 <br /> Date 0 <br /> Print Name G r �_ r /! �` — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �7 <br /> WORK PLAN DATED: <br /> / Date Issued �/7 A-2— Area <br /> Application Accepted By —'T—T <br /> Date Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHHHEECK�# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ 9/27/00 <br />