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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />I <br />ENVIRONMENTAL HEALTH DIVISION PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />ORL <br />SITE <br />MITIGATION <br />UNIT IV <br />0,05- D# <br />/1Js <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 />�+ LAssessor's <br />WELL LocationCross <br />nStree City NLJ Zip—,L Parcel# 0,--1 <br />PROPERTY Owner�_TS/�C Address ff-j' �fiC��s _City ���� ZiP�c�,,2`1Z Phone# �� 3 <br />c 2j6S lztl 1 po �Lic#t���Z)Z Phone#y6� ���✓� <br />C-57 Contractor/ c -r Address /4 YM City /► Zi <br />onsult I / L• / iGt N Addressrf <br />Sub Contractor <br />GIS Coordinates: X <br />Y 3 Township Range C: Section <br />WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br />NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 OVER -BORE <br />0 SOIL BORING # Per 0 PRESSURE GROUT <br />D,VVELL# i i'l� <br />'Other: Grout Specifications <br />!fid (' <br />j — S— c� � n *r s,: �� <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />R -MONITORING `HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ,.R.NO WELL CASING DIA-, <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS ' <iy TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7� �/ TREMIE TYPE TO BE USED: AAUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 11hyes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 6a <br />0 OTHER:_O OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 4A-0 (if YES, list specificatio s here):^ S <br />'COMMENTS: <br />NOT OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules an egulations, and all applicable California State 1Laws. <br />Signed x <br />Title/Company <br />me t <br />/GG t� Date <br />Print Na <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /�G <br />Date Issued Area vU <br />Application Accepted By Date <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />03--orU7 <br />COMMENTS /CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />X32 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encr� Q t doD� 9/27/00 <br />