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■ WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHSREHD) S UNIT IV <br /> 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE <br /> PERMIT EXPIRES okdebedIApplication is hereby made to San Joaquin County a Permit to construct andor inr.Wf the wrscrridThs appkatton 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 D-Tsion <br /> WELL Location mit. (`�c�1C ty{ Rr,6,rihc0-+ Assessors <br /> Cross Street city Stock, ,a+1 zip S �qty Parcel# (CL-2 70 <br /> PROPERTY Owner <br /> 5±0 n t�: Address ,,F�,t r _ <br /> 77 > firP city) t( `v Z1p r� [! <br /> Qhcne# <br /> C-57 Contractor q r _4 Address _7�3 FIts Ira/ &^Cryo <br /> City "•,r Zip '77Sr2-Ltc#w3`'/`7 hone#�I� 2 <br /> Consultant I Sub Contractor Fv1vt I Address WL - <br /> GIS Coordinates X y <br /> Township Range SeCbDn <br /> WORK TO BE PERFORMED <br /> XNEw WELL/BORING(CPT GEOPROBE HYDROPUNCH,HAND-AUGER OTHER`) <br /> 11 SOIL BORIN # Q DESTRUCTION{choose type below) <br /> WELL# 0 OVER-BORE <br /> 'Other u Q PRESSURE GROUT <br /> COMMENTS Grout Specifications <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC.-t NS <br /> 0 MONITORING HOLLOW STEM DIA OF BOREHOLE !` SINGS? rr <br /> D EXTRACTION d AIR HAMMER/DRIVEN CASING THICKNESS MULTIPLE <br /> OF CASING 0 YES `ANO WELL CASING DIA. _ <br /> VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL �( []STEEL PVC [I OTHER <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED Yes TREMIE TYPE TO BE U ED ❑AUGERS HCSE <br /> In SOIL BORING p No (NOTE MAXIMUM FREE-FALL DEPTHBIS 30') <br /> HAND AUGER GROUT SPECIFICATIONS 7-J-r r t,­- <br /> 11 OTHER_p OTHER APPROX BORING DEPTH <br /> 'BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED b <br /> 'C OMlVf ENTS `(if YES,list specitcabons here) <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> CALL THE UNIT fV INS rECTOR 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, Rules and Regulations, and all applicable California State Laws <br /> Signed x Title/Company ^� <br /> Pnnt Name <br /> DEPAN I rvIFNT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE ADDRESS &0� <br /> WORK PLAN DATED. <br /> Application Accepted By <br /> Date Issued <br /> Grout Inspection By Date a <br /> Destrucbon Inspectron By — Final Inspection By Date <br /> Date <br /> COMMENTS ICONDITIONS <br /> COUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> ;RECID 8Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authoriz4tlon to sign permit Encroachment doc 9/27/00 <br />