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WELL PERMIT APPLICATION FORM VYP= <br /> L _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 2 4 ZNtl1 <br /> SAN 304 E. Weber, Third Floor, Stockton, CA,, 9520210 <br /> � f <br /> ENVIR(jNMENT r,rALt N <br /> (209) 468-3449 0 IV <br /> PERMIT/SERVICES NON REFUNDABLE PERMIT EXPIRE I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and for,^istatl the work described This application is made in compliance wth San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Heal•h Services Envi nnmental 4eatth Division <br /> Assessor's <br /> WELL Location 1876 Cctxtta C1Ub_ 3L"id- Cross Street MSS11X1 City_%OC'ktCYt Zp Parcel# tX11470 j <br /> PROPERTY Owner W_ & 1475. FaMlal SXIChezAddress_ 1633 W. Wahl t City agile t,Cn _zip 95293_Phone# M464-1291 <br /> C.57 Cortractor V-W Address P.O. Box 51 00-b- Vista zip Llc#_229D4 Phone# 707 374-2815 <br /> Consultant/Sub Contractors gn'�neam� Address 13% E. 1 % City W)0iLT_d_.,Lic# 5513857 Phone# 530 868-5300 <br /> GIS Coordinates X Y Township 1N Range 6E__ Section 4 <br /> WORK TO BE PERFORMED_ <br /> 'UNEW WELL!BORING(CPT GEOPROBE,HYDROPUNCH HAND-AUGER OTHER-) d DESTRUCTION (choose type below) <br /> 1]SOIL BORING# (1 OVER-BORE <br /> WELL# R-1 0 PRESSURE GROUT <br /> `Ocher Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING &HOLLOW STEM DIA OF BOREHOLE 't MULTIPLE CASINGS) a YES :R NO WELL CASING D14L <br /> 0 EXTRACTION it AIR HAMMER)DRIVEN CASING THICKNESS' Ch 40 TYPE OF CASING f]STEEL :@ PVC p OTHER <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 71 TREMIE TYPE TO BE USED f]AUGERS gHOSE <br /> (I AIR SPARGE a PUSH POINT .GROUT SEAL PUMPED []Yes :0 No (NOTE MAXUMLW FREE-FALL DEPTH 1S 30') <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS neat Gilgit: with C5%bmtcnit;e <br /> ff OTHER 11 OTHER APPROX BORING DEPTH, 30 3 BOLTED TRAFFIC BOX or []STOVEPIPE <br /> remve7 CONDUCTOR CASING PROPOSED? no (if YES list speraricat ons here) <br /> `COMMENTS <br /> NOTg: 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 Ordinan , Rulesgpd Regulations, and all applicable California State Laws <br /> Signed xTive1Company � -- S <br /> r <br /> Print Name L.. Cmvexse Date �'.2 3 ' 2ck;,/ _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' r <br /> WORK PLAN DATED: /0-4-0 0 ! %41 – <br /> Appitcabon Accepted 13 Date Issued r!� Area 104 O � <br /> Grout Inspechon 8 Data f=inal Inspection By Date <br /> Destruction Inspecbon By Date <br /> COMMENTS J CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 13Y DATE PERMIT/S VIC EQUE # INVOICE <br /> S RNC-57 WC -WAIVE C-57 Letter of Authorization to sign permit Encroachment clot 9/27/00 <br /> SG <br />