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1 WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UION <br /> MT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS -EHD) �hIT V <br /> 304 E . Weber, Third Floor, Stockton , CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made :Pompliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmentatilealth Division. <br /> /r,�/1 Assessor's <br /> WELL Location 6 30 rat` '' yen - e Cross Street l'o'.� efee Ove, City • J raa t<lLo Zip 9 - © 0 Parcel# b "t51-- 360 -03 <br /> PROPERTYOwner Perxo Cr1. ne,4r( Address / S"36 dV. Jl� ±zrdr Sf , CityS_i _CALt-., Zip vi.Phone# <br /> C-57 Contractor ):ls ' 1 )1 Address 175"O & u-e !Y&v cl Cityarr% ✓re�ip 9y -a , <br /> K \A& ' C. Le <br /> Consultant / Sub Contractor JevVia✓}Hi Address .1k; Pe L. City lfi Kyb, Lic# Phone# .7 o9� ;77Y r/ S <br /> GIs Coordinates: X , Y., Township a h/ Range G G Section <br /> WORK TO BE PERFORMED: <br /> 6NEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH , HAND-AUGER, OTHER') p DESTRUCTION (choose type below) <br /> S 3 OIL BORING # .5 U OVER-BORE <br /> WELL # n PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> JJMONITORING HOLLOW STEM DIA. OF BOREHOLE " MULTIPLE CASINGS? U YES PrNO WELL CASING DIA: .7 r <br /> U EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS &-//. Ho TYPE OF CASING: U STEEL ",PVC BOTHER: <br /> U VAPOR p MUD ROTARY DEPTH OF GROUT SEAL.?'?' t3 7 r TREMIE TYPE TO BE USED: @ AUGERS U HOSE <br /> U AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Ynne�(s U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING UHAND AUGER GROUT SPECIFICATIONS: ly� ar CLK:w �ee� r— <br /> U OTHER: BOTHER C-( r APPROX. BORING DEPTH t�f i - / �� ' $BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? IV� ( if YES, list specifications here): <br /> •COMMENTS: C /� % /:./a : v- r//✓ fy loo r I wcG/ d'b Y✓-/ <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 Ordi ancces, Rules and Regulations, and all applicable California State Laws. [n <br /> Signed x f / y �/ i1 '�"e- Title/Company cs(2cY/' V'Ce�'YJ lJ M& r+ /w ✓ Caj`'r `r r'e"�. <br /> Print Name L. ��- /7. / �" Cv 1". Date T�7 4-e-� ID <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> Application Accepted By h/ 4 � L/ r%� Date Issued Area <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection B ate <br /> - COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Autho zation o sign permit_ Encroachment dot_ 9/27/00 <br />