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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 /> 61ookCi ItioKv+Ale-A1 6-1 (:* sa%-t, Assessors <br /> WELL Location Ckwawalo /}krorw, + Wa-loALr Cross Street City 'Si ye-le—+Z?V1 Zip Parcel# 39A <br /> PROPERTYOwner St.e- 0,.*06c-4" Address City Zip Phone# <br /> So." *05 <br /> C-57 Contractor VIrov%*.1G 7-KC Address 2.110 A41p6ry1S Ave.. Cityl.�-w�ro Zip915111-ic# 9L4 Phone#510-548-41% <br /> Cor► or wr'tU 188 Fr•►akc- LV&St <br /> Consultant/Sub Contractor Te.,.knolegieu.=wt Address Cir. Stt. Z City5'oclC+Or1 Lic# Phone#.Z.01'Z3q-0018 <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 /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?0 YES R/NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DE PTH OF GROUT SEAL Nk TREMIE TYPE TO BE USED: 0 AUGERS J-IOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ff"4es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> eSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: [OTHER Dir&&t I�uSl1 APPROX.BORING DEPTHS" 040-e. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �}. CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> 'COMMENTS: Pk .%& .LL Ev%Vi,rgo%meyt+o,1 Si♦t- ASSe-SyrNaln."�': Inya�ra►�<<i�•� oltra.c-E- Dbt51� <br /> Y'1 v- foil 0.Y1A Y'bt4v%a1 w&-t&V a IM <br /> NOTE: OFFSITE FrnRINGS 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 Regulatio , and all applicable California State Laws. <br /> Signed x U, r Title/Company Gry 52ry M Q r D rl o-r <br /> Print Name DO.V 14 14W o to Date 4 // 8 /n z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 7/� Area - Eos <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 /> f0 <br /> 9/27/00 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />