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WELL PERMIT APPLICATION FAM SITE <br />[RECEWED <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />DEC % 4 Z001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (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. <br />Assessor's <br />WELL Location �UJ' L'A't'0'A(- Cross Street I�'f 2-v5 City I � `� Zip Parcel# <br />q `03 - `�Cfl'3Z9 <br />/1� 'LL -u' Address City i Zip S 3�� Phone# <br />PROPERTY Owner � �"��� �e �' �`~ � � `� �� <br />C-57 Contractor �� �,^ L"'��' Address 3C4 54`� �` S (�� <br />4 Cityyb[ S�'� Zip�SZ�Z Lic# 'C3 Phone# 7 — 3� <br />Consultant/Sub Contractor T� PA)s. Address ll l L�� 0Utl',. City %LJ �� Lic# Phone# �j y ZLZ <br />GIS Coordinates: X Y Township Range Section <br />W RK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNH, HAND -AUGER, OTHER') <br />SOIL BORING # <br />[] WELL # <br />Grout Specifications: <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />USH POINT <br />SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_O <br />OTHER <br />'COMMENTS <br />0 DESTRUCTION (choose type beIV) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE )--' MULTIPLE CASINGS? 0 YES `&NO WELL CASING DIA: kL <br />CASING THICKNESS iJ 11A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL [ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 'V -Ko (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: cl`}— <br />APPROX. BORING DEPTH I ( 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />,Ak/W L1iti--' Title/Company �L �31c-tiS <br />Print Name D "1`, Q'`^- (ti -i Date I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: -4-L Gt+1 1 ,1 <br />WORK PLAN DATED: Iz 1 2-0 I <br />Application Accepted By Date Issued ) / Area <br />Grout Inspection By �� -c Date U- — Final Inspection By Date <br />Destruction Inspection By Date <br />!` RAAACKITC /!`n K1n1T1n A1C• <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />3<0 <br />C) y o3 <br />inn <br />C-57 WC= WAIVER_ C-57 Letter of AuthorizaTion TO sign permlT cncruuc.r1rnu -, • - <br />