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WELL rJERMIT APPLICATION Ft,,4M SITE <br /> MITIGATION <br /> SANNVOAQUIN IRONMENTA COUNTY HEALHDS ONPHSEHD)PUBLIC HEALTH SERVICES UNIT IIV <br /> � 344 E. WebThird Floor, Stockton, CA., 95202 <br /> Weber, (209) 468-3449 <br /> 101 NON-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSUED <br /> Application is he,2y 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 1 A-A IV Cross Street Mai0-- <br /> �l City /�,� Zip�3Parce[# <br /> PROPERTY Owner C Or Ma e Address , ev rr City✓l�iG-4P LCL Zip gS3jKPhone# 2aES 1 � <br /> C-57 Contractor!i�1 c Y�} 11/?� Address �;�l U_�• W)?��Prue n--city M n Cc t'Zip!r Lic#Phone# .�S <br /> Consultant/Sub ContractordlUGn ZP �°U�iruilti+l'rfhPddress3 5 It City�TzJLtlY1Lic# LPhone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# /V1WJ -� /Vl W _ 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORWG HOLLOW STEM DIA.OF BOREHOLE 1 4 MULTIPLE CASINGS?[]YES O WELL CASING DIA:aq <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STE )�OVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ' TREMIE TYPE TO BE USED: X-AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes RNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 0'} <br /> 0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: 4e4h" s' /6 4Ck- 16Y1YGih: <br /> Il OTHER:_0 OTHER APPROX.BORING DEPTH 30BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?./1/U (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 /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x (��- — /f J� ____Ttle/Corr pany <br /> Print Name 11, in �M /1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: JILE C�Q <br /> WORK PLAN DATED: <br /> Application Accepted By ate Issued d Area <br /> Grout Inspection By Date 7 n Final inspection B Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS-- <br /> ACCOUNTING <br /> ONDITIONS:ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 5-0 1 1 `t S '340 of <br /> C-57 WC -WAIVER C-57 better of Authorization to sign permit Encroachment doc 9/27/00 <br />