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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />SFP 17 2004 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENViR�i . i II�ALI H (209) 468-3449 <br />PFR11<iiI /` 1-'RJICES <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />oi�j <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 <br />Health <br />Division. <br />U� Cit S �17 —Zip c5 -Z04 Parcel# R-7'��- <br />WELL Location ��Z N- Y��4 Cross Street ,' pp i Y <br />�Gaillr 3,w �'l�a� itiY�9c� (Jz/— City ��, ZipS�`' ' Phone# <br />PROPERTY Owner i'OSCo /�U✓tcCc ,,{,, )?j Address �f�� , L O <br />2 /Vo4 Address-�— - 'c- 4&A -- ADC c4pV6 -/1 - &'-? -6,' <br />� J5 - <br />C -57 Contractor � <br />C�It # Phone#6/& 8(foyc <br />�0� lv�-w.cizuh� Address J�I7 ���Srr>� 17� City <br />Consultant ub Contractor ��'� Jf <br />Y _ Section <br />GIS Coordinates: X /h+� / A- Township /vw- Range \ <br />WORK TO BE PERFORMED:DESTRUCTION (choose type below) <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 ^` <br />D OVER BORE <br />0 SOIL BORING # <br />t� WELL # ;-i s , <br />t`� —� Grout Specifications: <br />'Other: <br />COMMENTS: 4 - <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />KAIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_O <br />OTHER <br />'COMMENTS: _ <br />16' 620'. Sc t'"' <br />TE BO <br />1✓✓t 5k"tt, �j - <br />Z <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE._ MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS /�; _TYPE OF CASING: 0 STEEL ,KPVC 0 OTHER: <br />DEPTH OF GROUT SEAL `- rO-7 TREMIE TYPE TO BE USED: 0 AUGERS ,HOSE <br />GROUT SEAL PUMPED: aYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: &�''4- �� ^ <br />APPROX. BORING DEPTH 17 �i BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_ <br />CONDUCTOR CASING PROPOSED?�_ (if YES, list specifications here): <br />�. , ...,I- L i'>n/ ,, , rle r.%j_..... /L4Slrt1 bi<14V L✓ <br />I.�,hL,-,� c ro — <br />NOTE: OFFSI �.INGS REQUIRE ACCESS ORE CROACHMENT 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 Ordinances, Rules nd Regulations, and all applicable California State Laws. <br />�/'f SUS �►sl- �.sEC�z <br />T�-tc <br />Signed x itle/Company J 4 /-7 <br />Date <br />Print Name_ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />AJ - �q�—a �i W <br />v Date Issued_ <br />Application Accepted By -4 <br />Grout Inspection By_ <br />Date Final Inspection <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SER EQUI <br />CC, <br />-i7 D� 39 z2 - <br />C-57WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc <br /># I INVOICE <br />9/27/0 <br />