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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 and/or install the work described This application is made in compliance w=th San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Heof Division <br /> WELL Location__.1 9L� A�/�c'r� ���-� Cross Street r. �`sF.�; City K,-' I44�� zip7532 Parcel# )-"o ��L <br /> PROPERTY Owner C� / Address �� �! cf City I / ., l cit-Z�p� Phone# <br /> C 57 Contractor- Dy-II!. Address 95 Zip_ �3 Lic# Phone# ZL-L g13 Ste" <br /> Consultant/Sub Contractor un Sir n •w.�_Address City �`��'I�' l�c# Phone# 5- r F-x`139/ <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED DESTRUCTION(choose type below) <br /> ff NEW WELL/BORING(CPT GEOPROBE HYDROPUNCH HAfID-AUGER OTHER') 0 OVER-BORE <br /> „SOIL BORING# / 0 PRESSURE GROUT <br /> 0 WELL <br /> 'Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> R MONITORING HOLLOW STEM DIA OF BOREHOLE yN MULTIPLE CASINGS?0 YES [ANO WELL CASING DIA N <br /> Q EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL O PVC []OTHER <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-1;,1:)---vi TREMIE TYPE TO BE USED 9 AUGERS ❑HOSE <br /> R SPARGE B PUSH POINT GROUT SEAL PUMPED d Yes No (NOTE MAXIMUM FREE-FALL DEPTH 1S 30') <br /> CIL BORING 11 HAND AUGER GROUT SPECIFICATIONS A1.­�- �M7 = - <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH /yU"� p BOLTED TRAFFIC BOX or 0 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 es and latlons, and all applicable California State Laws <br /> Title/Comp1 <br /> an r <br /> Signed x4 , <br /> + r�/ Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS c's Prvti �– <br /> WORK PLAN DATED. <br /> Application Accepted By k <br /> s t`� ��✓�, Date Issued r t- ` f~-,��� Area + <br /> Grout Inspection By <br /> Date Finat Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ('COUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 <br /> U ge. �t� c'_ct�• er � UOc�S (� Ca <br /> ` /27/DD <br /> C-57 WC - AIVER— C-57 Letter of Authorization to sign permitEncroachment doc 9 <br />