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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> T*,'!!('� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> �� _ ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> AP,�,, B PH I: 18 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> kpplication 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 <br /> Health Division. <br /> 12f City 'f\ <br /> C1m Zip�Parcel# 005 D90 <br /> Cross Street - <br /> WELL Location r\�� <br /> PROPERTY Owne�l,`�UMV���ti' -'�M1 6!d1 ddress�j, �( ��at 0� ZiNw)) ne# 3. �1J1L' <br /> C-57 Contracto L Address it Zip I��Licll� Crhone i'`Ii[q <br /> �iJ�]� `T`can� �� �D�_.�u <br /> Consultant/Sub Contractor ddress City�i�Lic# Phone <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p 0 OVER-BORE <br /> Q SOIL BORING# _ _ _� PRESSURE GROUT <br /> ELL# 'M�f'1— � k�.yiS�Js� V 1 <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MULTIPLE CASINGS?BYES ONO WELL CASING DIA: <br /> ;OONITORING �OLLOW STEM DIA.OF BOREHOLE TYPE OF CASING: 0 STEEL 'xPVC B OTHER: <br /> 0 EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE B PUSH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County 00i9ances, Rules ptd2Regulations, and all applicable California State <br /> to Laws. <br /> Title/Company <br /> Signed x <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� F <br /> WORK PLAN DATED: <br /> LU <br /> Date Issued <br /> /� �Z- �i�r�r, `' AreLOP 0� <br /> Application Accepted By �AON1N �gFS <br /> pDate Final Inspection By <br /> Grout Inspection By --n--- <br /> UBI�C. <br /> Destruction Inspection By Date <br /> COMMENTS/CONDffIONS: <br /> ACCOUNTING ONLY: AID# #�-'D <br /> fkPE CODES FEE INFO AMOUNT REMITTED CHECK# CBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> permit_Encroachment doc 9/27/00 <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign <br />