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WELL PERMIT APPLICATION FORM <br /> -, <br /> ol, r SAN JOAQUIN COUNTY PUBLIC HEALTH SMITIGATION UNIT N <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHQ) <br /> ,IAN % 4 ZOU1 304 E. Weber, Third Floor, Stockton, CA., 95202 -` <br /> O Nif <br /> (209) 468-3449 <br /> EN\tIR()NMS'vT hEAI.RK �r <br /> N N-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> pERMlT/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or ristall the work described This application is made in compliance with San <br /> Joagwn County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental alth Division <br /> WELL Location 1�ntxV Club BLyd. Cross Street CIty.ao2l .Cxt <br /> Zip Parcel# Li7(4'lC7fnrt <br /> PROPERTY Owner tt. & M—J- 1MJR1 S31±P7Address 1b W. City —ZIP Phone#_ 269 464--1291_ <br /> C-57 Contractor V.W Address P.O. Bax 51 cit- Vista Zrp <br /> 1 Lic# gLO4 Phone# 707 374-2815 <br /> Consultant!Sub Contractor M >7pZmeff�sAc'dress % E. Bamer St City ,Uz# 513857 Phone# 530 668-M <br /> GIS Coordinates X._,Y ,Township 1N Range--6E—Section 4 <br /> W RK T SE PERFORMED DESTRUCTION(choose type below) <br /> >CNEW WELL!BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER ) (I OVER-BORE <br /> >CNEW SOIL BORING# p PRESSURE GROUT <br /> 24VELL <br /> Grout Specifications <br /> 'Other <br /> COMMENTS <br /> TYPE )F WELL INSTALLATION TYPE CONSTRUCTION SPggEPATIONS <br /> p MONITORING &HOLLOW STEM DIA OF BOREHOLE lflrr , _.MULTIPLE CASINGS? [j YES R NO WELL CASING DIAD" - <br /> []EXTRACTION 13 AIR HAMMER/DRIVEN CASING THICKNESS ^TYPE OF CASING []STEEL :R PVC BOTHER <br /> [}VAPOR []MUD ROTARY DEPTH OF GROUT SEAL--L—TREMIE TYPE TO BE USED [)AUGERS gHOSE <br /> S RGE <br /> IR SPA []PUSH POINT -GROUT SEAL PUMPED []Yes :0 No (NOTE- MAXIMU A FREE-FALL DEPTH IS 30') <br /> ` OIL BORING []HAND AUGER GRQUT SPECIFICATIONS I1E'ati QTI�it; Wlttl(5Y--bH7fante <br /> �UOTHER ,{1 OTHER APPROX BORING DEPTH 301 BOLTED TRAFFIC BOX or (]STOVE PIPE <br /> recovery CONDUCTOR CASING PROPOSED? OO (if YES,test spearications here) <br /> *COMMENTS <br /> NOT : 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 to accordance with San Joaquin <br /> County Ordinan , Rules &pd Regulations, and all applicable California State Laws <br /> Signed z TitlelCom. _ <br /> �. 0m�� Data <br /> Print Name DEPA MENT USE ONLY <br /> � j <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J , <br /> WORK PLAN DATED' <br /> O� —O t `� <br /> JIF Dale Isst ed <br /> Application Accepted By Date= <br /> Grout Inspechon By Date Frna!Inspection By <br /> Destruction inspection,By Date <br /> COMMENTS I CONDITIONS <br /> — <br /> COUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SVVIC2EQU691T# INVOICE <br /> C-57 WC -WAIVERC-57 Letter of Authorization to sign permitEncroachment doc 9/27/OC <br /> EE1rS6 P60Z 65 OT OOOZ/5I 4T <br />