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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 /> 814mc14 (*: bo%Av%Aa.A 67 .r-Au rurw., Assessor's �L <br /> WELL Location C ko n,%e 1, U PR It 'lNa.loeCross Street City Sive-k—-O YI Zip Parcel# 32A a-ft%' J <br /> PROPERTYOwner 64LL 0."IO�cl►a-� Address City Zip Phone# <br /> SO." *05 <br /> C-57 Contractor Virov%,LY. I.nG.. Address 2.110 Aa(aw+S Ave. CityL.a�✓o Zip'I1571Lic# 9L4 Phone#510-$(m$-46740 <br /> COa Or r►✓ r88 Fr�►Ki'� west <br /> Consultant/Sub ContractorTe.aknoleaie T- ddress Ga'✓. ; Stt. I City:5+ock+0n Lic# Phone#Z0'{-,2,3''1-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`) H DESTRUCTION(choose type below) <br /> H SOIL BORING# H OVER-BORE <br /> H WELL# H PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> H MONITORING H HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?H YES R/NO WELL CASING DIA: <br /> H EXTRACTION H AIR HAMMER/DRIVEN CASING THICKNESS ISA TYPE OF CASING: H STEEL H PVC H OTHER: <br /> H VAPOR H MUD ROTARY Dl PTH OF GROUT SEAL Nh TREMIE TYPE TO BE USED: H AUGERS V HOSE <br /> H AIR SPARGE H PUSH POINT GROUT SEAL PUMPED: ees H No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING H HAND AUGER GROUT SPECIFICATIONS: `l <br /> H OTHER: W'0THERDirL&t ?"&4 APPROX.BORING DEPTHSu- 040.0. H BOLTED TRAFFIC BOX or H STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> 'COMMENTS: PkASm it Ev.v►,rony►nmy}e►1 Si+&. Airs. + vws" <br /> NOTE: OFFSITE MORINGS 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and II applicable California State Laws. <br /> Signed x " L. Title/Company Eve V SaNw 1r <br /> Print Name Dc'V 10` w O d:'j Date 4:�2d!/,n Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By /d ���/ Q�-L�C Date Issued YG2' Aread <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 /> p� 5— e 2S R# 0'9 �-- !o <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />