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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 anti the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> P"otic- Ljorlcs R1,3k} of dy Assessor's <br /> WELL Location(Wtba.r Ckostn&lM�ME,_C7eex�rossStreet City 'J+'oaI. +oyl Zip` Parcel# <br /> otrarw <br /> PROPERTY Owner ?"611 i c- 1/J0r kS Address City Zip Phone# <br /> fist/ <br /> C-57 Contractor !�Z V-4Lq"l Iv% SI{IA Address 'IS 0 166 4- " City s,t-,M2Zip'4553 Lic# #01 Phone#9 VS-313 -$800 <br /> Gen.lor F--r'1U /8$ Fra.►+k Irk%+ <br /> Consultant/Sub Contractor Teeko%o1egi l.,*.I r%c... Address Cir-.-, S?a._I CitySfo L,F *K Lic# Phone#2G`!'ZT'1"OS I8 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WO K TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> OIL 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 �O WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Jul A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL N A TREMIE TYPE TO BE USED: 0 AUGERS W�OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ees 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> eSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: [MOTHER C-F "r APPROX. BORING DEPTH I Z O ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> -�}- CONDUCTOR CASING PROPOSED? N A_(if YES,list specifications here): <br /> 'COMMENTS: PIn0.SQ .l4 ENVIy'pY1Wl�QK�0.� Si�2 AySe�sS�►v«.w�'' GPT �ooYiv�.gS. �v�crCac.l�w.ay.F <br /> e.✓vtn.� 'f" o.'t}a�k.a o1 <br /> NOTE: OFFSITE BORINGS 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 Regulation and all applicable California State Laws. � <br /> 1�1a�- <br /> Signed x l�.�� �X' � .. Title/Company D� <br /> h U. R �f <br /> Print Name T�V V l� ' `J�1 "�ZL Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 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 /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 9/27/00 <br />