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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />// /, �iJCj.{ FrC,v�,N f ver s�^� S4scK�.n VS Assessor's <br />WELL Location x"07 Cross Street City Zip Parcel# <br />PROPERTYOwne�r/C,-y J / `�<<^^ f By?1Address A/3 r4�u-t City �a C Zip 9-Tk'yPhone# 'F 14 yyy %ZOd <br />C-57 Contractor V f W /I, -1 Address �0X 4/� City�f/c -"-- zip �SGy/Lic# 7209 Phone# 7°7 3)y2 j'/S— <br />Consultant / Sub Contractor <br />IN G /'A4 "- *-a. t Address 3 0.5-0s/, <br />City r`� <br />7072 9°phone#'F/(' f 7� /`+(3y <br />GIS Coordinates: X <br />Y Township <br />pLic# <br />1 <br />T ,y Range ,` <br />0 E Section /C <br />WORK TO BE PERFORMED: <br />[] PUSH POINT <br />[] SOIL BORING <br />[] HAND AUGER <br />XNEW WELL / BORING ( CPT, <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, <br />OTHER-) %% <br />0 DESTRUCTION (choose type below) <br />0 SOIL BORING #jJ <br />0 WELL # Q S — S l <br />(/ <br />e' C y e,' (�v "� <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />"Other: <br />/ GROUT SPECIFICATION <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[] MONITORING <br />"­'10LLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />[] VAPOR <br />0 MUD ROTARY <br />XAIR SPARGE <br />[] PUSH POINT <br />[] SOIL BORING <br />[] HAND AUGER <br />0 OTHER: <br />[] OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_R MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: 2 " <br />CASING THICKNESSYCA y0 TYPE OF CASING: [] STE L )rVC 0 OTHER: <br />DEPTH OF GROUT SEAL 6-20' TREMIE TYPE TO BE USED: 0 AUGERS ROSE <br />GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATION /Vea { ��"" { - fje^ ^' 1'/,,'7 <br />APPROX. BORING DEPTH .30 FG` f VOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? v ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br />* CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />`2J Sr cn�..,.�.� f-/ S�,oc�;.l,'rf �lvall.ee <br />Signed x � Title/Company 2 / <br />Print Name <br />Q f -t""— %; Date Z �J / o / <br />SITE MAP IN UNIT IV F14 ADDRESS /WORK PLAN DATED <br />EPA T1 T USE ONLY -) <br />Application Accepted By -�� - Date Issued2" ea /'\\ <br />Grout Inspection By / Dateal Inspe.' on By Date, U2 <br />Destruction Insoection By / Date /,; 15 , J / j <br />COME( N S J CONDI ONS: v L <br />ACCOUNTING ONLY: Al D# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />C-57 WC/WAIVER C-57 Letter of Authorization to sin e Encroachment doc 7/17/00 <br />y f — <br />