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• ORIGINAL <br /> 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 /> WELL Location P' <br /> ]/5/ 4C/F/t XyeA rVE Cross Street RQ 11V V0eA S'TvctsaN 9S=OZ Assessors <br /> City Zip Assessor's <br /> /09—/60-0/ <br /> COLGEL,E 209 <br /> PROPERTY Owner SANJ OAyolm DELTA Address SAYE AS W--de City Zip Phone# 95r/,S03S <br /> C-57 Contractor dR/-`-GC /^J.5/7-0 Address 950 HaWE .calG City/sA.e r/Ncr�ip Q�/53,3LiaY �hone# 3135'900 <br /> ConsultantISub Con VactcrZ1I1V1,C4W1VeY Wz ,w0/ W4Z <br /> dress /000-A O.f'/t L.s c s't ih,p(AcEnT/.Pic# 1'yi?YSPhone# 611-FSZ/ <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PEIl <br /> []NEW WELL/ ORIN CPT GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# o OVER-BORE <br /> nn ) 1 p WELL# o PRESSURE GROUT <br /> 'Other: ( � / 1, Grout Specifications: 7,eF <br /> E/W& .e 17/Y TE.e/r�iVII+IdN <br /> /J <br /> COMMENTS: r ° �&Wj ail 710 L.e�oE <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?n YES []NO WELL CASING DIA:_ <br /> []EXTRACTION []AIR HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: []STEEL p PVC []OTHER: <br /> []VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> OSOIL BORING [)HANDAUGER GROUT SPECIFICATIONS: <br /> []OTHER;_0 OTHER APPROX.BORING DEPTH []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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nces, Rules nd Regulations, and all applicable California State Laws. <br /> Signed x �J—� Title/Company Pct/�EA�f" EN✓/ieONIYE�FA[ Avo�T <br /> Print Name-51111/1/t . 27' ,/17- Date �O Z7 0 0 <br /> DEPARTMENT USE ONLY ' <br /> SITE MAP IN UNIT IV FILE, ADDRESS: � ,0 <br /> WORK PLAN DATED: / Zocp— <br /> Application Accepted By Date Issued /-'!a—oy Area 09A ✓ <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> V 04 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 — 035154- I-2. cZplf n02 -5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc 4" 9/27/00 <br />