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WELLPERMIT APPLICATION FOKM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC H =ALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVI 30ION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stoc ton, CA., 95202 <br /> (209) 468344 <br /> NON-REFUNDABLE PERMIT EXPIRES YE R FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install Line 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 HellrithSDivision. <br /> AssesS,�rN Zip q � ParcelW 2 a dZ_ <br /> WELL Location �7' t/"GTn� Cross Streetle-'e4yD City ZoP s� � <br /> City Zip Phone# <br /> PROPERTY Ownee rr Zddress <br /> C-57 Contractor <br /> ,�l�'q �,� Address <br /> Consultant I Sub Contractor <br /> Address City Lic# Phone# <br /> Township Range Section <br /> GIS Coordinates:X Y _ <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) . <br /> XNEW WELL/BORING(CPT,GEOPROBE,HYDROPUN�H.HAND-AUGER,OTHER- a OVER-BORE <br /> SOIL BORING# _ r n ]]PRESSURE GROUT <br /> Q <br /> WELL f2lra9r.E ✓a�C� ' S� .rc-,� t� <br /> Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE <br /> E OF CASING:p ST YES O L Oj] WELLPVCD OTHERDIA. <br /> l] EXTRACTION aAIR HAMMEWDRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: 0-AUGERS 13 HOSE <br /> []VAPOR 0MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Ye 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')501L BORING j]HAND AUGE GROUT SPECIFICATIONS: <br /> []OTHER: _� <br /> OTHER'' r4G r APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROP D? (if YES,list specifications here): <br /> `COMMENTS: JP T°�--�s�? Z L'� SIN <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMu REPERMITS. <br /> NSP INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQ <br /> I hereby ce i that have prepared this application and that the work will be done in accordance with San.Joaquin <br /> County Or a ces, u e Reg ations, and all applicable California State Laws. <br /> TitlelCo parry <br /> Signed x Date _/q�sTz- <br /> ! <br /> Print Name 4"6 44NDEPARTMENT U E ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Datelssued���- p,rea6l �n� <br /> Application Accepted By Date <br /> Date Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By' Date <br /> "14 11 111111jill <br /> COMMENTS/CONDITIONS: D Pr <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35ol $�i 3S�f R s o ao3�i�� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> 9/27/flQ <br />