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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 /> 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,Chpptgr 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Block I: A.&A bSto►Noslwr.s. Assessor's 1� I <br /> WELL Location M,'"r, (aro�r►�+ t C W►ra ru.l Cross Street City S{'oe1C.}'OY1 Zip 5102 Parcel# 30A O. <br /> PROPERTYOwner Stt- 0,J1b6&1%&J Address City Zip Phone# <br /> So." ?0S <br /> C-57 Contractor Vlr•OMQ1C Znc.• Address 2.110 /dlJD.M5 Ave.. CityLta+jro Zip IIIIS�Lic# 9L1 Phone#510-$b$-41r� <br /> ew <br /> Cor wrtU 188 Fee-^k- West I, <br /> Consultant/Sub Contractor Te-e-k�►r%olea►ieS =NGAddress Cir. S-ft.. I City:{'ock-+Oh Lic# Phone#2-01-13" -O$18 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Wf4EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> n WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> G MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2." MULTIPLE CASINGS? 0 YES R/NO WELL CASING DIA: <br /> n EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: 0 AUGERS 14iOSE <br /> 0 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: ees 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �1 <br /> n OTHER: VOTHERDir L&t ,&&I, APPROX.BORING DEPTH I&& %koe. n BOLTED TRAFFIC BOX or a STOVE PIPE <br /> �}. CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> 'COMMENTS: FIr►ASm 1L kwdro.wlie- , dfrmc-F Dt4s6 <br /> ri r Soj I a.KaL rat...r%d wo."t&V' S06 W% <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 Regulations, nd all applicable California State Laws. u_ <br /> Signed x l Iti /� Title/Company (�vw- ��• "ap- .. <br /> Print Name D0.V i of W DO Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> If/ <br /> Application Accepted By Date Issued Y/�1/6 Z Area r/ _6 LIS <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# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Q P if /7O a- G O8 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />