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ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />I'I MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />oil ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 6/144Q <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 Health Division. <br />'J / / Assessor's, / <br />WELL Location //�`5� j.' L ��1D0'S�. Cross Street JAIrC"dA.t City SZd & Zd-nl Zip Parcel# /%.epi 7- �(o� �d <br />PROPERTY Owner&F, !F• Wl4ice - Sc,4' ._Address 1726 � - (�-� ST. City S N US Zip PS -112- Phone#G0'-/) O / -W <br />(�� 32, 33 i=(('�s] CiK�J S r. ��,1v r, r! 631 <br />C-57 ContractorvjEST Address_ Si U 7�. R City i�A ✓� Zi Lic#� r97 i Phone# ,6 0701 774 <br />Consultant / Sub Contractor A 4� ✓L- Address b S��410 00, City570Zk7,,/ Lic#/P�227 Phone#I�lCi�/� `f 7 IDC�� <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: so <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) 191 <br />0 SOIL BORING # 0 OVER -BORE <br />KW ELL # kj 1,L) is 0 PRESSURE GROUT <br />"Other: <br />PE CODES <br />Grout Specifications. <br />�. <br />COMMENTS: <br />REC'D BY <br />DATE PERM QUEST # <br />INVOICE <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS „ <br />7 <br />�IfMONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE � ", MULTIPLE CASINGS? 0 YES 4NO WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS �,O qa TYPE OF CASING: 0 STEEL 0 PVC NrOTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL a) TREMIE TYPE TO BE USED: fKAUGERS 0 HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: PD -a `"'Y ,V17 TYPE :rl7r <br />- f <br />0 OTHER: <br />_0 OTHER <br />APPROX. BORING DEPTH ) ✓o,L " BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_ j0 (if YES, list specifications here):_ <br />'COMMENTS: <br />\ <br />DI�fL �i 1 Ml.11,7/ 'Cl�l4yl.t�r�fi(J <br />iLicell(ZL�PLsI�� U�i�L; t <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 Ordinances, Rule�and"RRegOla ions, and all applicable California State Laws. vr►AICIi> <br />Signed <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Z <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Title/Company <br />DEPARTMENT USE ONLY <br />s <br />Date <br />Date <br />Inspection By <br />ek S -3b <br />L- <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERM QUEST # <br />INVOICE <br />SR#D�J3�16 <br />V' WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit ncroa��ennt doc— 9/Z7/Uu <br />