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[RECEQ`vJ ED WELL PERMIT APPLICATION FORM <br />JAN 2 2002 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 j <br />PERMIT/SERVICES (209) 458-3449 O R l G I N A L. <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 Deveicpment i tle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Civision. <br />Assessor's <br />WELL Location 71 S �wl�n Cross Street `JOGi h' , Zip % G' Parcel# <br />PROPERTY Owner L «�- c� i I ' °Address ('"L'' (r"° 1 '� l) ' i City —ZIP -2 11 1 u J Phone# <br />C' � City< , 7� i� /S tic# G,,> Phone# `/lam 7-rUl� <br />C-57 Contractor_ t �?- Address >> �r: p�r <br />Consultant /Sub Contractor A(�'- !-Address <br />`� 32 5L1Gv /err City S JL �? Phone# Z � % <br />PE CODES <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />REC'D BY <br />DATE <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, <br />HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />SOIL BORING # <br />�_(6�,{ �V�ti S 0 OVERBORE <br />T � PRESSURE GROUT <br />"Other._ K—< <br />11 WELL # <br />4 <br />Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />1 <br />a MONITORING <br />a HOLLOW STEM <br />DIA_ OF BOREHCLET � MULTIPLE CASINGS? 0 YES (I NO WELL CASING <br />TYPE OF CASING: [] STEEL ❑ PVC a OTHER: <br />a F_,C' TRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />(J VAPOR <br />MUD ROTARY <br />DEPTH OF GROUT SEAL n fii fe TREMIE TYPE TO BE USED: Q AUGERS 0 HCSE <br />p AIR SPARGE <br />�USH POINT <br />GROUT SEAL PUMPED: a Yes 3, 4o (NOTE: MAXIMUM FREE -FALL DEPTH ;S 30' ) <br />"OIL BORING <br />]] HAND AUGER <br />GROUT SPECIFICATIONS: <br />o CTHER:_ [] OTHER_ <br />APPROX. BORING DEPTH _ --7j] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /� (if YES, list specifications here): ____ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEN I t'tKM1 I J. <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 />Title/Company 6eeo G _ " L <br />Signed x ,Q ^______'__, , <br />Print <br />Y1 All )i <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued Area <br />Area <br />Grout Inspection By r/L S Date C — Fnal Inspection By Date <br />Destruction Inspection By Date <br />c-,;, I <br />DEPARTMENT USE ONLY <br />D- <br />COMMENTS / <br />ACCOUNTING ONLY: AID# <br />/. T j 1J <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT�12ERVICE;RIEQUEST # <br />INVOICE <br />C -57 WC= WAIVER C-57 Letter of Authorization to sign permits Encroachment aoc_ �� <br />