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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 /> JUL 2 3 2002 <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 DevelopnlJit_I,,ChWter� 5 an St�dardsPSan 5�agKie D County Public Health ServicesE�r ,{� � Tt � <br /> WELL Location F'0(.'Ta�SS"oTD`L(Jk�/U �iSiJ�'�CS sTSttreet N,4vy D,eiv City STC�tTC� Zip 5�Z�ln Parte E��O��� <br /> PROPERTY Owner ST7 C C�vycJ i i� Address �ZO� W W ASN117ER>1U�T City SiCCKTCN ZiP V Phone# <br /> 9Sy2 y <br /> C 57 Contractor . I�AZM►�r Address 3233 F�rz6nL� 20l City2RNCt1� Zip Lic#59197 Phone# 633-727b <br /> Cniz0o A /j nvcir0 <br /> Consultant/Sub Contractor SECOK Tn�rMMATIAn CAddress G01-I I41Cb0)L'I Rd City C0.203wh Lic# Phone# <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER") 0 OVER-BORE <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: P1eASZ Set 11r7-46d n Fo 2Ms L)SnN6 veLLS Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> EXTRACTION RAIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC 0 OTHER: v, <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> g'AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING H HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH D <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: * LE S SGE ATtAGN �n S17Av6 U"L - i S F <br /> v <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. of <br /> I hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a Acesland Regulations, and all applicable California State Laws. <br /> Title/Company Sri"op �r � nh/K2- lAIC <br /> Signed x I <br /> Print Name '4 Date -7&z/2 7 <br /> DEPARTMENT USE ONLY <br /> ,7 r <br /> SITE MAP IN UNIT IV FILE, ADD ESS: ` Sri <br /> WORK PLAN DATED: O C JR Gv <br /> �"Q� Date Issued Date Final Inspection OZ Afe�9•(s0 O! C <br /> Application Accepted By By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> LOUNTINIG ONLY: AID# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign p9�27�00 <br /> permit Enc:I OaChf6,;ilt <br />