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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> rENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance with San <br /> Joaqu n County Development Title Chapter 9 1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> '',�yy Assessor's <br /> WELL Location �S �u/rte+cr "- 1+U Cross Sleet U. /� °�{ City /"�+i'�C't Zip X337 Parceln <br /> PROPERTYOwner/Y1y,?ktrJz `,/ .P Address /001 C.tk1J1 C'Y /yls���4 —Zip ?s3:7Phone# <br /> C-57 Contractor Address <br /> Q I/ <br /> Ki M City �s-//�Z3p ?KS3 Llan Phone-- TZS- 3�3'S�IJa <br /> Gam,S � <br /> Consultant l Sub Contractor.4 11 r Ri ,Ie Address iHl7G�' Cit} 44V, Lic: Phone# /L <br /> GIS Coordinates X Y To% nship Range Section <br /> WORK TO BE PERFORME=D <br /> 0 NEW WELL 1 BORING(CPT GEOPROBE HYDROPU CIF HAND-AUGER OTHER ) 0 DESTRUCTION(choose type below) <br /> SOEL t30RING n 0 OVER-BORE <br /> 0 WELL 0 PRESSURE GROUT <br /> *Other Grout Specdir-ations <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �/� <br /> [I MONITORING []HOLLOW STEM DIA OF BOREHOLE I MULTIPLE CASINGS-) 0 YES []NO WELL CASING DIA ,49— <br /> r <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS -1 TYPE OF CASING 0 STEEL 0 PVC []OTHER <br /> 0 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL sal { TREMIE TYPE TO BE USED JaAUGERS 0 HOSE <br /> []AIR SPARGE ❑PUSH POINT GROUT SEAL PUMPED 0 Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> }OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ,OIL BORING <br /> UOTHEft APPROX BORING DEPTH 0 0 BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?1V!2 (if YES list speGfications 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 Ordinances, R s lations, and all applicable California State Laws , <br /> 00, <br /> Signed x TttielCompany Q' r ��d <br /> Date 0 <br /> PnntName DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS <br /> WORK PLAN DATED: 1 � o( <br /> Applicalton Accepted By Cj(-)C'k- �"�is-�`�'bv�\ _ _Date Issued /c�-7 Area <br /> Grout Inspeciron By (ro �vt/\ Date Final Inspection By Date <br /> DestruOon Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AIDS <br /> E CODES FEE INFO AMOUNT;REMITTED CHECK# REC'D BY DATE PERMTTI SERVICE REQUESTINVOICE <br /> (Sn F a�\ts k lou o ti n'25 (Qq <br /> C-57 WC - AIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />