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WELL PERMIT APPLICATION FORM <br />RECENED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />JUL 10 2003 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 <br />PFRMIT/SERVICES <br />SITE <br />MITIGATION <br />UNIT IV <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 9-111,5.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />5;0447N Z5';",dt2 Assessor's <br />WELL Location r3Wwfrf''/ CECT /EY /gyp, INO Cross Street G'�CY/l£i� City S?�/�7'4 y Zip Parcel# o F -y'4 <br />PROPERTY Owner C '7—r Q'� S7GU/--�NAddress ?'ZS— X1 t7,4 tWOO SS�T-- City �7dG(�llY�✓ Zip nWZ- Phone# 0%-� �0�3 <br />.�1�C�a p q� / p <br />C-57 Contractor�� �iuLG//Y�jAddress 36�Z Off'/ �'i1�2 City LAC�b✓ Zip I�/ l Lic#%/%S7ePhone#!r6 ci�it7'��!(J`/ <br />Consultant / Sub Contractor. Address 34/7 ZZ -4 �d City L o✓ ic# Phone# <br />GIS Coordinates: <br />u <br />Township <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />[] SOIL BORING # <br />,WELL# <br />*Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[] MONITORING <br />HOLLOW STEM <br />EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />[] VAPOR <br />[] MUD ROTARY <br />[] AIR SPARGE <br />[] PUSH POINT <br />[] SOIL BORING <br />[] HAND AUGER <br />[J OTHER: <br />[] OTHER <br />*COMMENTS: <br />Range <br />Section <br />[] DESTRUCTION (choose type below) <br />[] OVER -BORE <br />[] PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS / <br />DIA. OF BOREHOLE �� MULTIPLE CASINGS? [] YES [] NO WELL CASING DIA: (o <br />CASING THICKNESS 4/0 TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br />DEPTH OF GROUT SEAL t!:5—/5— TREMIE TYPE TO BE USED: ,AUGERS [] HOSE <br />GROUT SEAL PUMPED: [] Yes kN'o/(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH y�OLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 1/0 ( if YES, list specifications here): <br />nn/5-77Z�0C,7-25D Gt1%7—.t'4 1'41--/14/4/7' G✓%/LL DJC -v sGQ l7� <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 Ord inances,./Rules pnd Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br />Title/Company.�.��(7/4 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I <br />WORK PLAN DATED: - <br />Application Accepted By Date Issued 7 2t Area <br />Grout Inspection By Date Final Inspection By Date O� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />G�r+r <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQ U T # <br />INVOICE <br />3 �a <br />�G , o v <br />S S S q 1 <br />�- Zi <br />ICESR <br />P3 `f l <br />C-57 WC WAIVER_ C-57 Letter of Authorization to sign permit_ ent doc 9/27/00 <br />