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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Q` 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 OA/ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This appl,cat:an is made in compliance wth San <br /> Joaquin County Development Tille Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> t L C� Assessor,s/t 743 ,d ) <br /> WELL Location S ` tea _ 1 v� Cross Street Z �` City l' —Zip '7$�O Parcel#% O/ I / <br /> PROPERTY Owner rewQl f P_I a Q Addr r -EDC, C:ty l rbCIL._Zip 3 Z Phone#F 93 7�19d <br /> C-57 ContractorV �(���� �-._ Address_ L <br /> 9X510 oz <br /> Consultant/Sub Contractor I ! Address NzrP Z A-Ue Ctt��Lic#, ��hone# !t� <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> i1 NEW WELL l BORING(CPT,GEOPROBE HYDROPUNCH, HAND-AUGER OTHER') "DESTRUCTION(choose type below) <br /> []SOIL BORING# VER-BORE <br /> �+VELL# RESSURE GROUT <br /> 'Other (( �_ Grout Specifications <br /> COMMENTS e1\ Mw3��Il:i0Z. LOA+ae r— I t 12M-5S q7m,4 <br /> - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC[FTCATIONS <br /> j] MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?1]YES []NO WELL CASING DIA <br /> U EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING []STEEL p PVC (]OTHER <br /> V R []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED CIAUGERS Q HOSE <br /> (],WARGE D PUSH POINT GROUT SEAL PUMPED lI Yes (]No (NOTE. MAXIMUM FREE-FALLDEPT.H IS 30') <br /> Q SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS <br /> [] OTHER [I OTHER APPROX. BORING DEPTH [I BOLTED TRAFFIC BOX or []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 /> 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 CalifornI State Laws <br /> y <br /> Signed x ,p TitlelCompany �'� <br /> 'not Name �C4" //�0 SSG <br /> DEPARTMENT USE ONLY hate <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> NORK PLAN DATED: 2,:2:- <br /> p� <br /> Date issued C Q <br /> apphcai:an Accepted By +� ' Z z 'o <br /> 3rout Inspection By pate Final Inspection By Date <br /> 3estrucbon Inspection By Date <br /> :OMMENTS!CONDITIONS <br /> A NTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMfTTEQ CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> a <br /> -57 WC -WA C-57 Letter of Authorization to sign permit Encroachment doc 4127lDO <br />