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Py <br /> I <br /> r 1. WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> !� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNOASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N <br /> Yr ! <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 <br /> Health Division. <br /> zt z i tto V r AVL' Cross Street Gr. <br /> U hf Rul. City �'�c Zip's Parcek# <br /> WELL Location )p <br /> ' �c'F' " Zi L'i'S�1 Phone#XO�I-9 577-584 <br /> PROPERTY Owner C�G+i�nC' K'�UVL Address 620 vs � � • City r P�_ <br /> -Dd <br /> jJ <br /> 95Q0 '21 CitvM.J,W-7- ZiP3 u #` �IGh Phone#925-3/3-5' <br /> C-57 Contractor Lvaciq - Address � <br /> Consultant/Sub Contractor G <br /> SS oC- 4evr Address 111715 L411e (�+� Gity s U,# Phone# 549-22 <br /> ZI <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ESTRUCTIDN (choose type belg4v) I <br /> a NEW WELLI BORING(GPT,GEOPROBE,FIYDROPUNCH,HAND-AUGER,OTHER ) OVER-BORE <br /> a SOIL BORING# a PRESSURE GROUT <br /> �yW ELL#—MW' <br /> Grout Specifications: _ <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL , INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i <br /> " MULTIPLE CASINGS?0 YES NO WELL CASING DIA: <br /> U MONITORING a HOLLOW STEM DIA.OF BOREHOLE <br /> a EXTRACTION . a AIR HAMMeR/DRIVEN CASING THICKNESS N/A TYPE OF CASING: a STEEL 0 PVC (I OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> 16 TREMIE TYPE=TO BE USED: 'AUGERS a HOSE <br /> PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-PALL DEPTH IS 30') <br /> []AIR SPARGE <br /> GROUT SPECIFICATIONS <br /> a SOIL BORING a HAND AUGER : Csw�N -MTRAFFIC BOX or a STOVE PIPE <br /> BOL <br /> a OTHER:�iI OTHER APPROX.BORING DEPTH IIS A <br /> CONDUCTOR CASING PROPOSED? NO (if YES,fist specifications here): <br /> •COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this appiication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and ail applicable California State Laws. _ <br /> I Title/Company G. eL <br /> Signed x <br /> Date ! <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FELE,ADDRESS: C9 <br /> WORK PLAN DATED: 2- <br /> Date Issued Area <br /> Application Accepted By E e <br /> Date Final Inspection By <br /> Grout Inspection By -�� <br /> Destruction Inspection By .I Date <br /> COMMENTS l CONDITIONS: 'I. <br /> ACCOUNTING ONLY: AID# <br /> INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REE' BY D E PERMIT!SERVICE REQUEST <br /> i ,p <br /> W r> b�3 v OOZE'S� 9127i00 <br /> G-57� WCC WAIVER C-57 Letter of Authorization to s' n ermit. Encroachment doc <br />