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N I %J I I 111"L <br />WELL PERMIT APPLICATION FORM VJITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION(PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 �� <br />(209) 468-3449 RO6l�e <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A <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 />- Assessor's <br />WELL Location Cross Street ff-eto k 1 ,,I A e City S��'� �T�'l1 Zip �So�O `I Parcel# _ <br />�� City Zipone# <br />PROPERTY Owner 3c,�Iou n _Address <br />C-57 Contractory � 5,i1 S(-i(('��u Address 9SO 140wt /t Clty�'� 4,y,,z Zipyy53-3 Lic#t!6 y,17 Phone#925- 313 -5bc� <br />Consultant/Sub Contractor4lelleek eotin Tc,MedlAddress �% Slkk- R City��cckin�t Lic#������ Phone#�1io7-�GO�: <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT <br />'Other: <br />COMMENTS: <br />Y <br />Township <br />GEOPROBE, HYDROPnUNCH, HAND -AUGER, OTHER-) <br />V- OIL BORING # <br />� WELL # <br />Grout Specifications: <br />kV, vr- al:�&- � Ir,, <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />f�PUSH POINT <br />YI-SOIL BORING <br />0 HAND AUGER <br />p OTHER:_O <br />OTHER_ <br />'COMMENTS: L P 3 <br />A,. <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />[]PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE =%I MULTIPLE CASINGS? OYES ONO WELL CASING DIA:__ <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL Q Ft TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: T�yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />pp <br />GROUT SPECIFICATIONS: pot + 1,-& <br />APPROX. BORING DEPTH 1?0 �T 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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinapces, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />J Title/Company <br />Print Name Ilei Date <br />DEPARTMENT USE ONLY <br />4 <br />MAP IN UNIT IV FILE, ADDRESS: -vs / <br />WORK PLAN PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By Date Final Inspection By —A <br />Destruction Inspection By <br />Date <br />-0/ <br />NEM <br />�.ummcri i � r lrVl"LI I IVI�J. � - - <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />jREC'D BY <br />DATE <br />PERMIT / QUE <br />I <br />IN <br />I <br />1:501 <br />c <br />152, <br />�Oo <br />_ <br />n tn-7 inn <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit-Encrocthrliemt-cmc 7� "" <br />