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ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH bIVISION (PHS-EHD) UNIT IV <br />304 E. Weber, Thlyd Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 Y AR FROM DATE ISSUED <br />Application is hereby made to San Jcaquin County for a penult to construct and/or install the work dascrioed. This application Is r lade In oonpliance with Sar, <br />oaquin County Development Title, Chapter S-1115.3 and tt.e Standards of San Joaquin County Publlc Health Services. Enviror rental Heath Division. <br />WELL tocatlon_ l.� I.I �� Cross Street aSev ¢{ Assessors <br />�'�� Z:p Cf�, _Parcel# <br />PROPERTY Owner Address <br />j(Q5z1n� City�i}G� Zip 7& Phone#��- <br />C57ContractorAdcress2,j.SW_, �C. Clty ,c4, r Lpn�j �Lc lZ26clp^ones [kfa�-�-��2 <br />Consultant 1 Sub ContmctorC-.VA nud ZCCU Address <br />GIS Coorcinates: X .. Y <br />Township <br />WORK TO BE PERFORMED- <br />`01FJEW WELL 1 BCRINS (CP-, GEOPROSE, HYDROPLINCH. HAND -.AUGER, OTHER') <br />0 SOIL BORING # <br />XV=LL# KjW►r VAw wtuH-�— <br />'Other. GroLr Specifications: <br />COM Mf ENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />XV10N70R1NG <br />)<-10LLCW STEM <br />0 EXTRACTION <br />r, AIR HANWERDRIV=N <br />n VA."JR <br />0 MLID ROTARY <br />0 AIR, SPARGE <br />0 :1JSH POINT <br />0 SOIL BORING <br />0 HAN- AUGER <br />0 OT'r-ER: Ii CTHER <br />'CC <br />Range Secttur <br />0 DES7RUCTIO% (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />NSTRUC N SPECIFICATIONS <br />DIA OF BOR=HO' MULTIPLE CAS NGS? 3 Y=S BJ�0 WELL CASING DIA: 1: <br />CASING THICKNESS LU TYPE OF CASING: o STEEL PVC 0 OTHER: <br />DEPTH OF GROJT SEAL S TREMIE TYzIE TO BE USED: 0 AUGERS 0 HnSI- <br />GP.OJT SEAL PUVPED: U Yes _010 (NOTE. MAXIMUM FREE -FALL DEPTH IS 301) <br />GROJ7 SPECIFICATIONS: V otj' Ori A1C/ { <br />A=PRCX. BORING DEPTH <br />_ 0 BOLTED TRAFFIC BOX or p STOP=PIPE <br />CONDUCTOR CASING PROPOSED?P_Y�> ( IYE3, list spec:flcations here): <br />NUTi=: 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 !O�r an , R sand Regul ions, and all applicable California State Laws. <br />Signed x Tite/Company_ <z, 1p 'C' �Qpbi,\IS1 + 1�j O zem <br />Print Name ��A Dare 1� `Z 3 tV I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDREES <br />WORK PLAN DATED:_ p/ZZ <br />Application Accepted By Date Issued_`_ 1,ja/z Area <br />Crout Inspection By Date Final Inspec:lon By Date <br />Destruction irspecticn By Date <br />COMMENTS f CONDITIONS: <br />ACCOUNTING ONLY: A10# <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERM RVICE REQUEST # INVOICE <br />C-57 WC' -WA TI/Pn r-ri-7 1 t++ � <br />