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;RIGINAL <br />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 O N • l�S <br />03 <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 Develo ment Title,_Ch�ter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Fv� rtP� D� 1e� Assessor's <br />E � K'`` "' Zip l - c S Parcel# <br />WELL Location �e� �� �`/L/����Y �yl Cross Street City // <br />90') y City P Zip�yj- 2 Phone#C/rr�� <br />PROPERTY Owner f� /�c7Yl/ J V`C Address <br />V ��� rl,�,�k ��� Ci /vim zip9S2-y� Lic# /�-7S�Phon% <br />C-57 Contractor�i. GY'7d /L7 Address• h ,tc <br />c cYtic� Lic# ` Phoned <br />Consultant /Sub Contractor /C �� �/L' L / � Address } . i` JOS City <br />GIS Coordinates: X <br />��, ) Y �� G%� Township /L,,) Range /�-7 C. Section �r7 <br />WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br />,'NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, O HER') U� ��CG 1 0 OVER-BORE <br />SOIL BORING # �1,C 5 �'/ 0 PRESSURE GROUT <br />'Other: <br />0 WELL # <br />- /' �4 — 5 = <br />Grout Specifications: <br />COMIvt TS: <br />lr <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE , MULTIPLE CASINGS? II'YES ONO WELL CASING DIA: <br />0 MONITORING <br />;HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS5— TYPE F CASING: 0 STEEL )K?VC [] OTHER: <br />EXTRACTION <br />VAPOR <br />MUD ROTARY <br />DEPTH OF GROUT SEAL C,- - ,iF TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />MAXIMUM FREE -FALL DEPTH IS 30') <br />;AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: WYes 0 No (NOTE: <br />� / � / J" <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH /yt%� /I T3j-^ (2= ;$ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: <br />_O OTHER <br />CONDUCTOR CASING PROPOSED? itis ( if YES, list specifications here): <br />'COMMENTS: <br />Nr !L t <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 Regulations, and all applicable California State Laws. <br />Signed x Title/Company SJ- <br />Date If <br />Print Name �- <br />/LCc /SA -0" <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Y/ l Y2 <br />WORK PLAN DATED: X/''--/ <br />Date Issued O 0 Z Area— � 8 <br />Application Accepted By ate ry <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT /SERVICE REQUEST # <br />35wNWJ lJ4Z 0030 45 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit <br />f Encroachment doc�,4 <br />INVOICE <br />9/27/00 <br />�V <br />