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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> F 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMrT 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 descnbed This application m made in compliance with San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Pubhc Health Services Environmental Health Division <br /> Assessor's <br /> WELL Location • x Cross Street � �`'` 15City /7�TM �}``� Zips 33�` Parcel# Ilk- 0' 21 <br /> PROPERTY Owner ralc,n 1'�o s g T Address p �� City �� Z+p� Phone 2-A'7 <br /> C-57 Contractor (arc�f D��1� —C Address9� a � -1• x d _Ctryl��+ � zsp�$1553 Lic" Phone# `3z5"3/3--6-3 � <br /> Consultant ISub Contractory ,E-<-5Address P_/{-J�_City Phone# 9.LS-8�°"��9� <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> []NEW WELL/BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# G�- � � 2� _. 0 OVER-BORE <br /> 0 WELL# 17 PRESSURE GROUT <br /> 'Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 'Z// MULTIPLE CASINGS?0 YES [] NO WELL CASING DSA <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS V/� TYPE OF CASING 0 STEEL []PVC []OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /VO TREMIE TYPE TO BE USED GAUGERS [] HOSE <br /> 0ISPARGE $PUSH POINT GROUT SEAL PUMPED b4'es 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> L BORING j]HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH I tiO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? f"C' (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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances us an lations, and all applicable California State Laws <br /> f <br /> Signed x TiUe/Company <br /> Pnnt Name Date <br /> Z 2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS _� "1 OSOAA, <br /> 4 — <br /> WORK PLAN DATED <br /> Application Accepted By ::L � F- �' T +�^ Date Issued 31;2,-) Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> COUNTINGDS <br /> E CODESOUNT REMITTED CHECK#t ; 'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> � /i . /�31 oto 5�� t� <br /> C-57 ICEER C-57 Letter of Authorization to Sign permit Encroachment doc 9/Z��aQ <br />