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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,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Block 21 b0--A&A I,7 C7rwwt" Assessor's 1L 1 <br /> WELL Location Mimar AKeor.►0•CL.&.►ar. Cross Street City St0'-k— bV% Zip `ISZO2- Parcel# 34A <br /> PROPERTY Owner SLt- 0.*06r-k& 1 Address CityZip Phone# <br /> I s..n *05 <br /> C-57 Contractor VIrov% .% MNG• Address A41o.&"-o Ave• CityL.t I 1'o Zipl`�S�Lic# qL-4 Phone#510-548-44 <br /> Coin or wr Y{a /813 Fea Ak- W&%t <br /> Consultant/Sub Contractor"Te..'-kVaolegie u=NG•Address Cir. , Ste,- I City:S+ock-+0r% Lic# Phone#A.O'1-Z3-4-O$/8 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> a WELL# o PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING o HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?o YES R/NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: O STEEL G PVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 11Th TREMIE TYPE TO BE USED: O AUGERS J(HOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: ees p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING a HAND AUGER GROUT SPECIFICATIONS: ,1 <br /> 0 OTHER: [�OTHERDir&J' (?its)» APPROX.BORING DEPTHSu- 0446e. a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> 'COMMENTS: PRIASd Si♦t.. t^tid�l«. Aiv-,Lst I?L&sn <br /> ri r 60it O-Kd c►wt <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 app ication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulationsi and all applicable California State Laws. <br /> Signed x J Title/Company E^V• e.'r V. Co vLAo�' <br /> Print Name D^ d- � K w OOOI Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: /// // <br /> Application Accepted By/�/(�itgJ-e Date Issued Y� �2 Area <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 /> 6�� 06ag6047 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />