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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 4 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This application is made in compliance with San <br /> 2oaquin County Development Tale Chapter 9-1115 3 and the Standards of San Joaquin County Pubhc Health Services Environmental Health Division <br /> Assessors O <br /> WELL Location 33 r/,� Cross Street k1' y° ��fc City /�^�i<-��* —ztp 2$ ) Parcel#� ! � J 1-1 <br /> PROPERTYOwner e- r Lam' r 9r5Y3� Phone7_�I ���I I� y3 <br /> Address 1 jy� I rAi rf-�rc� r4J.s-. city :,-,}".a-�-r.4 2ip <br /> C-57 Contractor �r l(�r`,.. Address S° ' �"'' �.C�ry � '�'}'" - -zip �l�' -tilt# Phone# yZ5-3, ,5Y`e <br /> Consultant 1 Sub Contractor r /K. Address 2-'125- 10 L- !�^ o City IL_.,_ r/},. Lic# Phone# 2i5 - <br /> GES Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED DESTRUCTION(choose type below) <br /> 0 NEW WELL!BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER`) OVER-BORE <br /> 'SOIL BORING# [� 1J PRESSURE GROUT <br /> []WELL# <br /> `Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE-- —MULTIPLE CASINGS? YES [ANO WELL CASING DIA <br /> TYPE OF CASING 13 STEEL []PVC []OTHER <br /> ❑EXTRACTION n AIR F{AMMERIDRIVEN CASING THICKNESS <br /> VAPOR ©MUD ROTARY DEPTH OF GROUT SEAL'S�—r TREMIE TYPE TO BE USED []AUGERS 0 HOSE <br /> OSPARGE ;PUSH POINT GROUT SEAL PUMPED gYes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> It_BORING []HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER []OTHER APPROX BORING DEPTH BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_ (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 R s and ulations, and all applicable California State Laws <br /> I <br /> Title/Compan <br /> Signed x J �2 <br /> Print Name Date, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS Vy^7 L �'?r✓-A �-e <br /> WORK PLAN DATED: <br /> Date Issued <br /> Application Accepted By L <br /> oYc� -,� -3�� I Area <br /> Date Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS <br /> COUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> e�l gG T- 1a' j I 6 o �fiiz <br /> do�S 0-1 `� � <br /> 9/27/00 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permitX Encroachment dot <br />