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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �1 <br /> (209) 468-3449 1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D&TE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described This application 1s made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> jb K 5. CA,, rQa.k4bV L►'s6 W LAnW-,- gr3�,J Assessor's y3O_ <br /> WELLLocation. 1►� Cross Street r City Zip Parcel# I qb- � <br /> PROPERTY Owner PreLZE-1) PRit.0 PS Address 159 IS 5 AD-City (A11*t1d'P Zip 9S33OPhone# ,y <br /> �i5�43 .��,.ta + $31fbS <br /> C-57 Contractor L"'}`�Address 3`19 Sit 'y Pty -ClCli ! ` �s Zip`1 S Zl.ic# Phone# Z°g �7 `3'5'7) <br /> 3017 t-f ILS 6 %- XA, .- 9A'0eAA%j &'Ty y9$' <br /> Consultant/Sub Contractor sC-Z4,"g_ 'x^" `y'' ,A�dress 5-?.VV.- 'p" Llo <br /> D D City C-A-O& # Phone#(em.)�Lf-OYs� <br /> 018 Coordinates X _ � ,Y N r'' ,Township Fl9 O Range 3$ t Section 14c' <br /> Z <br /> WORKTOBEEE FO D <br /> NEW WEL J R C G�OP9OBHYDF]OUI�CH,HAND-AUGER,OTHER') []DESTRUCTION(choose type below) <br /> `'SG#_ I OVER-BORE <br /> a WELL# PRESSURE GROUT <br />*Other. Grout Specifications �"� ��'�' <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[I MONITORING a HOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASINGS?(]YES 11 NO WELL CASING DIA AJ"- <br /> 1]EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING p STEEL p PVC []OTHER I-"'A- <br /> 1]VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL A"t TREMIE TYPE TO BE USED Q AUGERS 11 HOSE <br /> 11 AIR SPARGE FPUSH POINT GROUT SEAL PUMPED p Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> IL BORING HAND AUGER GROUT SPECIFICATIONS Nom' <br /> R_ n OTHER APPROX BORING DEPTH O BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? � (if YES,list specifications here) <br />'COMMENTS <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 /> 1 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 t V. I _ _ Title/Company So, r C-�Lc 5 fM S X.as� asl�rc t t�C <br /> Print Name _T"I)PIOS y P Date `IlLyle <br /> DEPA <br /> RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S <br /> WORK PLAN DATED: -Z 7--O Z- ! Q <br /> Applicadon Accepted By Date Issued_ �/ �Q y Are <br /> 3rout inspection By Date f=inal Inspection By Date <br /> Destrucdon Inspection By Date <br /> COMMENTS/CONDMONS- 2f 1 <br /> ACCOUNTING ONLY AID# =Arlo <br /> )CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUESTT# INVOICE <br /> z3 •3 DD <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit, 9/27/00 <br />