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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNC IV <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 apprication is made N compliance wth San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Envimnmental Health Division. <br />WELL Location :400 N. F1 Dxc-rb St. Cross Street LirlCl9eV Gty ZIp2�202 Parcef#� <br />PROPERTY Owner Joe N4ileri —Address -400 N. F11 Elm -ab St- City Sboddm —zip- 95202 Phone#209/941-8230 <br />C-67 CvnlraCtor Address 2365 WigEFn Dr- city 2ip25Lie# 512268 P209/465-8712. <br />3450 E. Ori r>g 9t. 562/988-2755 <br />Consultant/Sub Contractor loll Address City Ian Phone# <br />GIS Coordinates: X Y Township TIN fango RGE Section 20 <br />WORKTO BE PERFORMED <br />p NEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER-) X DESTRUCTION (choose type bekN4 (7., <br />0 SOIL BORING # 13 OVER -BORE <br />11 WELL # KN 4PRESSURE GROUT <br />'Other. Grout Specifications: 511>ny <br />COMMENTS: lell-/L(i--e- / !M In I <br />TYPE OF WELL INSTALLATION *TYPE C1,WSTRUCTION SPECIFIC_ ATIONS 3/4'r� 1 <br />MMONITORING 11 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES )l NO WELL CASING DW <br />p EXTRACTION 17 AIR HAMMERIDRIVEN CASING THICIWESS .35" TYPE OF CASING: 11 STEEL )1 PVC 0 OTHER: <br />11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4' TREMIE TYPE TO BE USED: 13 AUGERS [) HOSE yr - <br />13 <br />0 AIR SPARGE itPUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) ?"� <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: We11 CLat>t - B31331ltP- <br />(I OTHER 0 OTHER APPROX. BORING DEPTH 251 BOLTED TRAFFIC BOX or. >p STOVE PIPE G <br />CONDUCTOR CASING PROPOSED? ( it YES. Ilst specifications here): <br />'COMMENTS, Spam ft ti ms abDve c7=2be the type cE wells to be mmed aril aba ftEd b7 *m smim Ta±u]-J. <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 />1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, R&d)9s and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />GL.. <br />USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 5 l <br />iMAIZ: <br />WORK PLAN DATED: <br />Application Accepted ByDate Issued <br />Grout Inspecdon By Dane Rnal Inspection By Date <br />Destruction Inscectlon By 4Ji� ,,.o Date / 2,/? --0/ D <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAM <br />PE CODES FEE INFO <br />AMOUNT REMITTED CHECK # REC'D BY <br />DATE PERMrr I SERVICE PEW # <br />QV1IO11cE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit 9/27/00 <br />