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WELL PERMIT APPLICATION FORM SITE <br /> 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 <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 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 /> Assess <br /> WELL Location ('<Ina fTW/ f9/J Cross Street �'�F� G`i'Y. City 7lDl�/1LIL/� Zip �I Parcel#ors <br /> PROPERTY Owner//4 T/_ /�/i7f�ll& ddress ,O,LAX /iJ`—�i Ciry/'i_ Zip /`��4Phone# �cZS=a�rf�Bf� <br /> C-57 Contractor YY Address e'1>4-City Ge�.c�/iW�-Zip S ZLic#7/750 Phone# <br /> S 3L.7 Kic%oc� �ti �TrcNv <br /> Consultant/Sub Contractor ��O/L Address oa —City­ CaRG�'Lic# Phone# P/��l/"o�lOa <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> �hIEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> ;,WELL# PRESSURE GROUT <br /> %Z✓O / FG-LS __- <br /> 'Other: <br /> _-G—root Specifications: 0 <br /> COMMENTS: ]'VL -Z <br /> TYPE OF WELL INSTALLATION TYPE ---CONSTRUCTION SPECIFICATIONS <br /> AONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES )rNO WELL CASING DIA: Z// <br /> 0`EXTRACTION n IR HAMMERIDRIVEN CASING THICKNESS 56/ Z/0 TYPE OF CASING: 0 STEEL XPVC []OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 70' TREMIE TYPE TO BE USED: JKAUGERS 0 HOSE <br /> 0 AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: Ayes []No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS: 6 /T Grf�G+IE�T <br /> 0 OTHER: N OTHER APPROX.BORING DEPTH � BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDYES,list specifications here): <br /> 'COMMENTS: 1r7D /GU' Citi 745;c—c'-, 9✓�-�� <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, uses and Rggulations, and all applicable California State Laws. �L <br /> Signed x - - ___ Tifle/Company <br /> Print Nam. e l/V7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS' o N <br /> WORK PLAN DATED: z o <br /> Application Accepted By Date Issued .F, I Zo to-Z Area <br /> Grout Inspection By nnn _ Date b i D Fnal Inspection By L C�--. Date 6 2S D <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# mat'. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REOUEST# INVOICE <br /> 350 •eo SZbZsFs (L( I 6 20oZ SR# C1 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />