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WELL rERMIT APPLICATION FUr2M SITE <br />MITIGATION <br />SEF 10 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 />C� �� n Assessor's <br />WELL Location % �(o 1, � -,CCAL) S� Cross Street C GLV l� �l City Cxn% ''� Zip s Parcel# <br />PROPERTY Ownerdk�vl*zz, ��w�y � Address �()(„ t✓L. 1 v�t� City }� Zip` Phone# LL:(— 4 (S -L(, <br />C-57 Contractor )P 'A4��i�� Address ZZ� ' city Su 'lWl'�l Kip5l `?- Lic#_Phone# -3 2.7�­ <br />Consultant / Sub Contractor A, LE Address City Lic# , D Z7 Phone# Yi 4� 1 - to(X- <br />GIS Coordinates: <br />,Y <br />Township <br />WORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />'WELL# i)4 i U.) <br />'Other: Grout Specifications: <br />r11AAMFNTq- <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE � <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'"ONITORING kHOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? 0 VNO NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS z TYPE OF CASING: 0 STEEL QVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL LC- TREMIE TYPE TO BE USED: WAUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 'ffNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER:_O OTHER <br />'COMMENTS <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Orddiinances,ules and Regulations, and all applicable California State Laws. <br />Signed x \1 r Title/Company <br />Print Name Date �n�% �� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accel <br />Grout Inspection <br />6 <br />d <br />Destruction Inspection By iJ Date <br />T <br />n} <br />rnRARiCu•rc l!`ntJrllTIr11JC• 1 f10iM %/ivfl,I7 � ✓ Prr wy�. <br />C-57 W_ -WAIVER C-57 Letter of AuthIr6 sign iermit Encroachment cloc_ v1c //VU <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />E 'D BY DATE PERM E EST # INVOICE <br />0 Z -1-L+ z2 <br />C-57 W_ -WAIVER C-57 Letter of AuthIr6 sign iermit Encroachment cloc_ v1c //VU <br />