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WELL rcRMIT APPLICATION FO"M <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 />SITE <br />MITIGATION <br />UNIT IV <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 Sari <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />`' C 1 I/ Assessor's <br />WELL Location $0� �, �( G✓V�O/I-I J'i Cross Street bUr't City �l Oc l� f"o�l Zip Parcel# <br />PROPERTYOwnerddress Fye pACx4+ City 5%c4tck-N Zip Phone# C/4ro- 0233 <br />C-57 Contractor (l)c43au.,4rd 'T�i�kl.b Address Y.O. l-BoK to CityR o UiStA Zipg4571 Lic# loo Phone# 0 1/.37(4w14 -U0 <br />Consultant/Sub Contractor Ai _ Assinc :r6C Address ((I - Lo- e- 96.1mtF City Sf.Lic# Phone# 5'74-ZZZ-1 <br />GIS Coordinates: X , Y , Township Range <br />Section <br />W013K TQ BE PERFORMED- <br />EW WELL BORING ('CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type beloW) <br />0 SOIL BORIN9 0 OVER -BORE <br />WELL 0 PRESSURE GROUT <br />'Other: # Grout Specifications: 13C. r\toAit� <br />COMMENTS: <br />TYPE OF WELL <br />`,MONITORING -' <br />0 EXTRACTION <br />RVAPOR 3 <br />0 AIR SPARGE <br />0 SOIL BORING <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />0 OTHER:_O OTHER <br />'CO <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S " MULTIPLE CASINGS? BYES XNO WELL CASING DIA: Z I t <br />CASING THICKNESS -S 0n CIO TYPE OF CASING: 0 STEEL )R:�VC 0 OTHER: <br />DEPTH OF GROUT SEAL 2 TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />GROUT SEAL PUMPED: ,Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301 <br />GROUT SPECIFICATIONS: Be-Atp N�g— Grow* <br />APPROX. BORING DEPTH &S�SI3S ,�OLTED TRAFFIC BOX or O STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 00 ( if YES, list specifications here): <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/Compan&�C—k 5 OC/f a t2. -S Tel c <br />Print Name ce--,a cV�_ Ms� <br />\1tODate �IiSQI <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT iV FILE, ADDRESS: <br />WORK FLAN DATED:_ 1 O <br />Application Accepted By Date issued Area <br />Grout Inspection BDate l ( Final Inspection 6y Date �� "`����// <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # R/EC'D BY DATE I PERMIT / SERVICE REQUEST # INVOICE <br />-25�� �6 1��� S�Z' ( l62� O�S R# <br />oachment doc 9/27/00 <br />C-57_ WC= ,_ WAIVERC-57 Letter of Authorization to sign permit Encr <br />