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WELL PERMIT APPLICATION FuRM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Assessor'ss ...a. a al <br />WELL Location ig 2-14' 5-afrz) Cross Street (444-‘1P-SCityc530(-04Yl Zipq -Z045 Parcel# .)- (1 - 2-5 <br />PROPERTY Owner1-441vet-,g1eracot I Address Ki2 r'•S'v.41-1) /4(2- City-C.--4-440 Zipq5202.,-Phone# • <br />C-57 Contractor We* Ha 2-- MAT-Addres3315; (tea- City.-C_ Zr51-Lic#55.4197:thonet04:' 658— 727( <br />Consultant / Sub Contractor AGE- Address a37 Skew) gekityg47)CO1Lic# Phone# % 7 lob (0 <br />GIS Coordinates: X , Y ,Township Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />; <br />04ERK TO BE PERFORMED: <br />W WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />(ELL <br />BORING # <br />ELL # <br />*Other: <br />COMMENTS: <br />O DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT <br />Grout Specifications: <br />DIA. OF BOREHOLE 1-3MCA MULTIPLE CASINGS? DYES <br />CASING THICKNESS TYPE OF CASING USTEEL flPVC flOTHER: <br />DEPTH OF GROUT SEAL5D TREMIE TYPE TO BE USED: AUGERS <br />TYP OF WELL CONSTRUCTION SPECIFICATIONS INSTALLATION TYPE <br />ATPOLLOW STEM <br />[I AIR HAMMER/DRIVEN <br />--7 /1 <br />WELL CASING DIA: / <br />ON ITORIN G <br />EXTRACTION <br />1] VAPOR <br /> O MUD ROTARY <br />AIR SPARGE <br /> O PUSH POINT <br />SOIL BORING <br /> O HAND AUGER <br />0 OTHER: <br /> OTHER <br />*COMMENTS: <br />NOTE: OFFSITE 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 />Title/Company C <br />e-rn Date <br />Area t ° <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS. <br />a HOSE <br />CONDUCTOR CAS7 P POSED? ( if YES, list specifications here): <br />iviali -Fog4t1 >7)s*/eX- - <br />GROUT SEAL PUMPED: fl Yes ArNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: -177-----1-7.-e01..b <br />APPROX. BORING DEPTH I 3'5 7 ,---eg-C7,111-'3OLTED TRAFFIC BOX or a STOVE PIPE <br />;1532_ Iva.-eiz)cN <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Cti4t3 <br />Print Name /74-07-•%- <br />Signed x <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 11144r4(r. ezatk <br />WORK PLAN DATED: a5 5-C4A 2-073 f4iDp rtlAe 211(1 /t1 • <br />Application Accepted By tzPV.PARSitti Date Issued/Q///O/ <br />Date Final Inspection By 4tle„.--e-q Date ICV/ <br />Date <br />P <br />ACCOUNTING ONLY: AID# : <br />INVOICE <br />PE CODES FEE INFO <br />5951 <br /> <br />•get- <br />C-57 WC -WAIVER <br />AMOUNT REMITTED <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />CHECK # REC'D BY <br />/0' <br />DATE PERMIT! SERVICE REQUEST # <br />00 r2---/ (of : <br />9/27/00