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WELL PERMIT APPLICATION FORMG`e� ION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES�D 1E ��, t�.)l <br /> t ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) OC 2004, <br /> "``dddd���'��' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONPJENT HEALTH <br /> PERMIT/SERVICE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I tion is made in comp nce with San <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This app Assessors <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health S;rvices,E�-0`Parcel#alth Division. <br /> WELL Location/O So S D,Ar�O,va ST Cross Street E, (,.10LTI/STCiry S�o�KY��•l Zp� <br /> _ ._-� „�L,,/y� Address ce c Ll,Arr OrD S�City S <br /> TOCK 7O,UZip����hane# 1. o� <br /> PROPERTY Owner` Jbo <br /> w Address AID.BOX 33� Ciry,eloV/ST'4Zip`�yS7 Lic#7 o79Phone# O <br /> C-57 Contractor LVOOA41l�� phone# S79 X33/ <br /> ..�.[ PAcM/1t�City MO 176s to Lic# <br /> Consultant l Sub Contractor.47G /LjE, f►TES Address 11,74 Section <br /> Townships Range <br /> GIS Coordinates:X�--.Y�� <br /> WORK TO BE PERF ORMED: 0 DESTRUCTION(choose type below) <br /> 0 OVER-BORE <br /> 0 NEW WELL/BORING(CPT,G O <br /> OIL BORINPROBE.G#HYDROPUNCH,HAND-AUGER OTHER!) 0 PRESSURE GROUT <br /> (/ _ <br /> DWELL# Grout Spedfic�atifns: <br /> Other <br /> COMMENTS <br /> TYPE OF WELL It! LAT10N TYPE CONSTRUCTION SPECIFICATIOfv1NULTIPLE CASINGS? YES D.NO WELL CASING DIA: Sh <br /> 0 MONITORING OLLOW STEM DIA.OF BOREHOLE ff A TI PE OF CASING: ()STEEL 0 PVC []OTHER: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 VAPOR 0 MUD ROTARY <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: as 0 Nc (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R-601L BORING 0 HAND AUGER GROUT SPECIFICATIONS: , <br /> APPROX.BORING DEPTH Tj 0 BOLTED TRAFFIC BOX <br /> p OTHER: 0 OTHER or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? CA�if�YES, � ceti/`%�ereS� <br /> -COMMENTS: E- TCS ,CE✓/SE.D K//-A� Fo� A NG 's GyQ 70>e� <br /> ,IfLFeDUG/n/G V ✓A,< clla.4idM aAr© SL <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances ules a d gulations, and all applicable California State Laws. <br /> TitlelCompanI'&� /—'�__I sem �7G <br /> Signed �" <br /> / Date <br /> Print Name DEPACRTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD RESS: ��✓ _g ^`'� <br /> WORK PLAN DATED: Q6 <br /> Area <br /> Date Issued d <br /> Application Accepted By DateFinal Inspectio. Date <br /> Grout Inspection By <br /> _ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNT N®ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE O REQUEST# INVOICE <br /> F9.o-0 `153 G-6 /o s/0 <br /> C- WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment docA/ 9/27/00 <br />