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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) o MWJEDD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 MAR 0 5 2002 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nn�� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is nFtleVi��R,f I� l lI T�7HEALTH <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environment lti$arl I I fl�."6 <br /> WELL Location nn I I Iy�h/A Assessors <br /> AQWry� 4 �T�CrossStreet City ( Zip Parcel# 13�]—Q20—OZ <br /> PROPERTY Owner alanAa K►chk-tid Q Addressh. „' /I,t <br /> fl r,� �/y� �'j„ ���,�� City/rar�(a `ZipgS�Phone# <br /> C-57 Contracto cry Gv Address f/hLq jl(fLflXL41���_Clty _ Zip- , Lic#��Phone n a'l�/1p <br /> Consultant/Sub Contractor Ji���� Address T�l�� ✓G Crty Lie# Phone#�I�O_o(OI.f)� o <br /> GIS Coordinates:X y 0✓ dVQL., g5b�0 <br /> Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> 0 SOIL BORING# a OVER-BORE <br /> WELL# {�V.I— I <br /> `Other: Grout Specifications: D PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE___ ' MULTIPLE CASINGS?BYESYNO WELL CASING DIA: <br /> sS <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES �J�,QTYPEOFCASING: STEEL 'PVC OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 20 y� TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> PAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FA L DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: n OTHER APPROX.BORING DEPTH S �In OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> *COMMENTS: CONDUCTOR CASING PROPOSED?�_(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/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY f <br /> SITE MAP IN UNIT IV FILE, ADDRESS: v <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Ins on By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cer« <br /> PE CODES FEE INFO AMOUNTREMI CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Spit <br /> C-57_ WC=W R_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br /> 0 46 <br />