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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Pu.loli� Works Ri�1ht-0f- to Assessor's 1� I J <br /> WELL Location(,Wi4iLe Cki►nKcl, Min1r, G-(rs Cross Street City 5tock—iO✓l Zip Parcel# sQ.� 0.1rG►�V1Q/t <br /> S+a„iilwK.i�pros ora <br /> PROPERTYOwner St-t- 0."II'C�c.�►�� Address city Zip Phone# <br /> . GS"I- 1? <br /> C-57 Contractor_ ��(9.QAA �1>rc� Address City—i , A-ic# _ Poi <br /> �Cona�ov- �E,wrtk. /88 Fr — West �l <br /> Consultant/Sub Contractor "(�e.c.�nIeaieS.ZNe.-Address Cir... Stt. Z City�{'ocIC�O+'1 Lic# Phone#.Z�7'Z3"t-O$18 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> o SOIL BORING# o OVER-BORE <br /> 0 WELL# H PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: �^ I �7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ` F>-r f7) <br /> 0 MONITORING H HOLLOW STEM DIA.OF BOREHOLE Z" MULTIPLE CASINGS? YES R/NO WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: O STEEL U PVC O OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL Nh TREMIE TYPE TO BE USED: D AUGERS J(HOSE <br /> 0 AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: l6es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: [OTHER Dirt& IP"sk APPROX.BORING DEPTH$" a�`t <br /> "ac p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �}. CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> `COMMENTS: P k*.%q. 1L Ev%V i V'o Kma yt+o►1 S i tt. Ae s,#-tS1'y%`vti't'; oLiv-d-r--t- D L&S h <br /> ri r fbi t a.KaL rbwhdWert'mw awn 1 Ev�crvo.clnw`a.r`t a.vvv�i{- w Tel. <br /> NOTE: OFFSITE ErORINGS 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 Regulati ns, and all applicable California State Laws. <br /> Signed x Title/Company �fit4Di- <br /> Print Name bo�V 1ok K• W o C of Date O Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: s <br /> Application Accepted By <br /> Date Issued 7/ ;/�Z Area�j_� <br /> L (°DS <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />