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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (SNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> AppI cation is hereby made to San Joaquin County for a permit to comh4 aWor install the work descnW This application is made in campitance with San <br /> Joaquin County Developrna t Title,Chapter 9-1115 3 and the Standards d San Joaquin County Public Health Somem, EnmronmwW Health Dnnsion <br /> Assessors <br /> WELL Location Cross Street�� City s +� Tip ,20 7 Paroe- <br /> PROPERTY owner Soh Address,tea-G%2- lea cry ��� ra 9 'v/ P A�9' `'�"3O°° <br /> C-57 Contractor Ow�b Addns�G (�c�c 336 cm�P:.G,f rp 9f�S7/1J !� Pr,« �7�7i� <br /> Consultant/�etdi'i/Xf7�'� Cr�_" �- Address .Sf City4le,�ic#j/ Phonedf,s �+�''s'✓Y'd <br /> GIS Coordinates X Y Township 2. _ - Range 646 SecLon Z/ <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) CkDESTRUCTION(choose type belom) <br /> D SOIL BORING# D OVER-BORE <br /> §WELL# on&e7 �/ RESSU E GROUT <br /> Other Grout Speaficabons 3 J'lr A iX/7aT G,/ S 3& 4 l� - <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES 11 NO WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL 0 PVC 0 OTHER <br /> VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED D AUGERS D HOSE <br /> AIR SPARGE D PUSH POINT GROUT SEAL PUMPED 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> t] SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER. OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC SOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list spomfiicatims 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 /> I hereby certify that I have prepared this application and that the work well be done in accordance with San Joaquin <br /> County Ordina ces, Rules d Regulations, and all applicable California State Laws. <br /> Signed x <br /> PnntNarne_. . r I"G' �on�cfsc _Date — G/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application AocVted ey Date Issued A� <br /> Grant Inspection By. Date Final Inspection By pate <br /> Destruction Inspection ByDatQ <br /> COMMENTS I CONDITIONS <br /> CCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> r-%7 Wr _WATVFD r-;'i7 1 sttor of /1istknri7ntfnn to e,nn nirrnet I=rv^rnnr hinnnt rinr o/ nn <br />