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� ORIGINAL <br /> � WELL PERMIT APPLICATION FORM SITE <br /> SAA^I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 /�� <br /> (209) 468-3449 (05- � <br /> s <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor Install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> Assessor's <br /> WELL Location_( ,/e e'--_mot.r� <br /> w Cross Stree a A City- ZipJ��Parcel# G <br /> PROPERTY Owner`ir �T �r7G" Address A,,,,b&19a k-y �/�C�itys��zip4� Phone# <br /> �2)L <br /> C57 Contractor Address2-'65–A4eg2j! City, 1 Zip�a�Lics*= Phone#g �12•� <br /> �— <br /> onsulta fSubContrectorK�9 ,A-k/dem Address.`a_j--E: 1-7 7Z Clty_2 Uc# Phone#m-e!E Y3— <br /> GIS Coordinates:XY---17—,TownshipA ) Range--2L--- Section! <br /> WORK TO BE PERFORMED: <br /> •DMEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> T' 1)SOIL BORING U OVERBORE <br /> WELL# U PRESSURE GROUT <br /> 'Other: Grout Specifice6ons• <br /> a <br /> COMMENTS' /n)/3—r �ianl�c+ c r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ';MONITORING )'HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?p YES kNO WELL CASING DIA• <br /> 22 <br /> U EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS sr-A 41 y TYPE OF CASING: p STEEL ]IfVC 0 OTHER: <br /> VAPOR 0.MUD ROTARY DEPTH OF GROUT SEAL �'S�� TREMIE TYPE TO BE USED: AUGERS HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: )KeS p No (NOTE: MAXIMUM FR1-EE✓--F_AIL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: I�r✓ Gr� �J,3 ` r <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH_ _ OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AAO (if YES,list apedficeg s 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 will be done in accordance with San Joaquin <br /> County Ordinances, Rules anOyegulations, and all applicable California State Laws. <br /> Signed x Tltle/Company Sc <br /> Date <br /> Print Name GC-C� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> �(�liat/l._ Date Issuewww�,iprsa <br /> Application Accepted By <br /> Grout Inspection By Dale Final Inspectio:,A <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: G 03-0/ <br /> ACCOUNTING UINFO <br /> AID# <br /> PE CODES AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � 32 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encro�B�t doOK ' 9/27/00 <br />