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WELL PERMIT APPLICATION FORM <br />/A SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />r ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stoc�ton, CA., 95202 <br />(209) 468-3441 - - <br />Application is hereby made to San Joaquin County for a permit to construct and/or install th <br />Joaquin County Development Title, Chapter <br />9-11115.3 and the Standards of San Joaquin C <br />WELL Location0&rl/j`Sx+, ? S•�,E.I� wtc(1D SA . —Cross <br />Street2 .I 3r�5I, <br />PROPERTY OwnerlJ�41A 01 OMCLi N Address 7«�/ti. rL� W((do <br />C-57 Contractor 1 WL(� TP(- Address Cit` <br />Consultant / Sub Contractor F7IC j f)G / rLViQ-t rtG Address ,Za MbM114D <br />GIS coordinates: X Y Township <br />K ff��llLL���-- <br />0 <br />� �, IZS �- o 13� .1 looS S. E I <br />WORK T t3E PERFORRiNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />°WELL # <br />"Other. t. f A � �5pec <br />COMMENTS: �f' <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATII <br />[] MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE <br />[] EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes <br />[] SOIL BORING <br />[] HAND AUGER <br />GROUT SPECIFICATIONS:_ <br />[] OTHER: <br />[] OTHER <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOf <br />"COMMENTS <br />X255 -&,z 4 72,0 <br />MITIGATION <br />UNIT IV <br />work described. This application is made in compliance with San <br />inty Public Health Services, Environmental Health Division, <br />Assessor's nom. _ <br />:ity c N Zip Parcel# 4uw <br />L City v Zlp S t� Phone# ' $� <br />�1 <br />�Zlp p Lic# 72p%4hone#-1 -Ylbo <br />kL_CityAk2�Lic# DZ Z- Phone# 6 - 47 /Z7 <br />Ran SectionCA <br />^ <br />v� <br />DESTRUCTION (choose type below - <br />[j:OVER-BORE <br />cations: <br />J5 �f <br />ULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />_ TYPE OF CASING: [] STEEL Il PVC 0 OTHER: <br />TREMIE TYPE TO BE USED: 0 AUGERS [] HOSE <br />p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />? (if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN <br />I hereby certify that I have prepared this application and that the wo <br />County Ordjj3ances, Rules and Regulations, and all applicable Califs <br />Signed x Title/Compar <br />Print Name <br />DEPARTMENT USE <br />SITE MAP IN UNIT IV FILE, ADDRESS: / (O(/' •..�� <br />WORK PLAN DATED: 3 'Z7_ -0L <br />Application Accepted I <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />ANCE FOR ALL REQUIRED INSPECTIONS. <br />k will be done in accordance with San Joaquin <br />rnia State Laws. <br />ate Issued S - ZZ -0 / Area aW <br />nal Inspection By _ _ .pate <br />i <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT 14VICE REQUEST# <br />INVOICE <br />o�- <br />A25,2, <br />C-57VWC ✓-WAIVER Athl C-57 Letter of Authorization to sign permitnc 9/27/00 <br />TA 39Vd EEVC89b59' 9S:rT TEtN'j'L0i-`_1_1 <br />