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WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F11 o, <br /> uh <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. 9� <br /> w 4 Assessor's 0 <br /> WELLLocation27�J SKin4�%1 Srr,k+ Cross Street Sin. Ra, City 5ioc.ktor. -zip Parcel# i4S-030-091 <br /> PROPERTY Owner gQ- RGO Address City Zip Phone# <br /> C-57 Contractor PSr ciZtna+ Address32Z9 +tLC57- 76 <br /> Spr-MA Ra4Cgity('�,.choc`Zip 45-74 is#s-s4`175 Phone# Ib b39-72- <br /> Consultant/Sub ContractorSEGcf: ink rc+i-io.anl Addresses►7 Rd, S-+ IZur\chekY�City C,G o,- Lic#1 - Phone#(g16)86(-o4C0 <br /> GIS Coordinates:X Y Township 111 Range 6 C Section 49 <br /> WORK TO BE PERFORMED: <br /> ]KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) H DESTRUCTION(choose type below) <br /> []SOIL BORING# 0 OVER-BORE <br /> WELL# IS-1.0 ZZ <br /> S- , .zS-3 . MIU-1-50 _:4/Z-MO- 6+--1Z p PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: /azf- Z cp `2," GIS j9 4.6:2 l!U- 1? -th4" � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r� <br /> p MONITORING HOLLOW STEM DIA.OF BOREHOLErit7 / MULTIPLE CASINGS?H YES )(NO WELL CASING DIA: 4 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCK,40 TYPE OF CASING: H STEEL )KPVC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL k-S �-ftt TREMIE TYPE TO BE USED: AUGERS n HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> `g OTHER:3_-S_ S�ri A 0 OTHER APPROX.BORING DEPTHS ZO Feet' )(BOLTED TRAFFIC BOX or 0STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N O (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 I 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 /> // <br /> Signed x- Title/Company PE1034_Dc} Na0%n5-r-1SG-CoR �r�ernA�mai <br /> Print Name cSf- 4VC_kl-2>-1or\►e_ Date �Z-19"01 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2-ADO 4r-' �- <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued /�7�/ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> �er+w <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 2- <br /> 'A'20 <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />