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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> 33 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> t1- ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third <br /> 9 )468Stockton, CA-, 95202 <br /> 3449 <br /> NON-REFUNDABLE RM P RES YEAR FROM DATE ISSUED I'�bon is made in compliance with San <br /> Applicabon is hereby made to San Joaquin County for a permit to construct endlof install the woemy described. This app <br /> Assessor 156 <br /> oa uin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Heal Division. <br /> q _ City I rfk;✓ lap p5,3 0"t Parcel# <br /> �� �t�� J!. .•` Cross Street <br /> � <br /> WELL Location Zi 95 " ` Phone#�7✓�� 3 <br /> �•.la �i :?�� Address �"1 ��5 � ��^•-�5>ata,°e City ( [TG P / <br /> PROPERTY Owner -w " ` u �j` � �; [1 rfj l rc# Is mhone#` <br /> � <br /> C-ST Contmc r i 1' phpn <br /> t-tldn:SS "�• JT ��, iH 1+W. w.' Llo# <br /> Consultant 1 Sub Contactor Range Section <br /> Township <br /> GIS Coordinates:X <br /> Y <br /> WORK TO B PERFORM OTHER') Q DESTRUCTION(choose type below} <br /> •y p OVER-BORE <br /> ANEW WELL!BORING .C ❑SEpOILBOR NGY#DROPUNGH,t1AND AUGER, PRESSURE GROUT <br /> ❑WELL# Grout Specifications: <br /> `Other: <br /> COMMENTS: <br /> npE OF WELL INSTALLATION TYPE GON57RUCTION SPECIFICATIONS <br /> r 'y " MULTIPLE CASINGS?11 YES �,NO WELL CASING DIA: <br /> HOLLOW STEM DIA OF BOREHOLE j PUC ❑OTHER:�� <br /> ❑MONITORING ❑ ,, TYPE OF CASING: ❑STFFL Q <br /> d TRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS 4° TREE TYPE TO BE USED: o AUGERS Q HOSE <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑VAPOR GROUT SEAL PUMPED= S,Yes ❑No (N <br /> p AIR SPARGE `RUSH POINT <br /> HAND AUGER GROUT SPECIFICATIONS: <br /> SOIL BORING BOLTED TRAFFIC BOX or ❑STOVE PIPE <br /> APPROX.BORING DEPTH rf%f�f ❑ <br /> OTHER: eAT k n OTHER ,f YES,list specifications here)' <br /> CONDUCTOR CASING PROPtOS�D. <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS pArRicENoR�LALcRE4u RED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR qg WORKING HOURS IN <br /> p <br /> rehave <br /> pared this application and that the work will be done in accordance with San Joaquin <br /> 1 hereby certify that P <br /> ns, and all applicable California State Laws- <br /> County Ordinances,Rules and Regulatio } F <br /> TittelCompanY�- � p (� <br /> Signed x \ Date <br /> Print Name _ DEPA tTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Area <br /> Application Accepted BY Dale - <br /> Date Final Inspection BY <br /> Grout Inspection Fay Date <br /> Destruction Inspection By <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> PE CORES FEE INFO AMOUNT REMITTED <br /> 07 <br /> c//0 7 2 d Pl 3 01) 6 0 2 l��4 2 <br /> C-57 9/27 <br /> WC -WAIVEC-57 Letter of authorization to sigh permit Encroachment doc <br /> R <br />