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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 /> 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 andlor 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 /> Assessors <br /> WELL Location 2-091-3 c..1 Cross Street tri LJ City 1; Zip 9,q 33?Parcel# Zoo 't+~ I <br /> PROPERTY Owner !'14 Address City - k ter, c� _Zip Phone# -7-0 9 <br /> C-57 Contractor ,i Address `�ao o�l�— City/ Zip 9y5S3 Lic# Phone# 925 "3!3-sr3�c <br /> Consultant/Sub Contractor}*w� �c -Z �'jf-+`-'f Address �'��-' �! }�^ ° City Pr"�'!!� Licn Phanen 52S$ -/93g/ <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORME <br /> 11.NEW WELL I BORING( PT GEOPROBE HYDROPUNCH HAND-AUGER OTHER') [j DESTRUCTION(choose type below) <br /> $'SOIL BORING# eir- ?y _ p OVER-BORE <br /> ©WELL# Q PRESSURE GROUT <br /> 'Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING 4 HOLLOW STEM DIA OF BOREHOLE -Z-' MULTIPLE CASINGS-? []YES ENO WELL CASING DIA <br /> d EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS�/�f/} ._..TYPE OF CASING [ISTEEL n PVC ©OTHER <br /> 0 VAPOR j]MUD ROTARY DEPTH OF GROUT SEAL /;'O — TREMIE TYPE TO BE USED ffAUGERS HOSE <br /> 0SPARGE PUSH POINT GROUT SEAL PUMPED Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> �"I $ <br /> L BORING U HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER 0 OTHER APPROX BORING DEPTH /zM� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED �1,Jo (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 Ordinance Ru s and ulations, and all applicable California State Laws / <br /> Signed x Title/Company <br /> Print Name AGI Date - Z- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE, ADDRESS 1_�Zv-? 3- t-j 05Ll^"1 -- <br /> WORK PLAN DATED:; I'a k i,_j I C, -� <br /> Application Accepted By i_!c L Date Issued ] Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> CCOUNTING ONLY AID# $ <br /> E CODES FE=E INFO AMOUNT REMITTED CHECK# RE'DBNY DATETPERM71M7/SERVIC7ER�EQUES #T INVOICE <br /> in <br /> C-57 WC =WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9127/00 <br />