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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNITlV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 v ' <br /> (209) 468-3449 vim`- <br /> NON-REFUNDABLE PERMIT EXPIRES'l 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 application Is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Stafidards of Sia J aquin County Public Health Services,Environmental Health Division. <br /> �}l " 3t E LJ�� � Assessor <br /> WELL Location G Cross 5_treet E � ��"�Se ON Zip9S_3k�, Parcel# <br /> rtgti - <br /> PROPERTY Owner n &+t 0,- <br /> z ;AddressOrd n City &'•z1 Z1p95`?.421 Phone#}Z4 <br /> C-57 Contractor Vk Addresses I tlrlf City 1Vrs - -Zlp �n Lic# Phone# r- y3 <br /> Consultant/Sub Contractor AddressCity U)^ Lic#2'Xa7'�6Phone# <br /> GIS Coordinates:X ,Y ,Township flange Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,BAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> WELL# [t1� _ 0 P ESSU�E GROUT <br /> 'Other: Grout Specifications: `G�. y� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE r� MULTIPLE CASINGS?I]YES NO WELL CASING DIA: <br /> [)EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS''ti�` " TYPE OF CASING: []S EE XVC []OTHER: <br /> r`.:-*.-%jjPOR I]MUD ROTARY DEPTH OF GROUT SEAL__V <br /> TREMIE TYPE TO BE USED: a AUGERS []HOSE <br /> SPARGE []PUSH POINT GROUT SEAL PUMPED: [)Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30") <br /> 's.= <br /> []SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: <br /> [] <br /> OTHER:—0 OTHER APPROX.BORING DEPTH*2d X 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 /> I hereby certify that I have}prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina es Rules an 9 ions,and all applicable California State Laws. <br /> Signed z s Title/Company ►�� <br /> Print Name YG iv r Date Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: V d S. S <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued <br /> Grout Inspection BY <br /> Date Final Inspection By Date <br /> _ ; <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> >_.;ZCOUNTING ONLY: AID# FAQUt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY HATE PERMIT/SERVICE REQUEST# INVOICE <br /> RZ 5-A <br /> C-57ZL WC -WAIVER, C-57 Letter of Authorization to sign permit chment doc 9/27!00 <br />