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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 />cAv-Z�, <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 />Assessor's <br />\3ac- w ce S -t ()o.,�C Sto 1,+ t 3 5 - ZSo-Ll5 <br />NELL Location Y �J Cross Street City <br />Zip <br />i <br />Parcel# <br />CHECK # R 'D BY <br />9.� hx, t Q 1 L <br />I-o3 Z 5 W ' ��r ^�r'C <br />s <br />City S ���a^ Zipn 52,)3 <br />Phone# <br />.ov�Z <br />DROPERTY Owner Ly. C-Address <br />CASby� -Z <br />` v <br />C-57 Contractor \V aW \�. Address ` �X y <br />S1,A__ Zip Lic# Phone# [ b 1 y 0, <br />—city-"- <br />� <br />Consultant/Sub Contractor\��� co _9 ��� Address\�\ S c <br />I � <br />CityM\�GtS�°Lic# <br />Phone#��°tsZ� <br />�1 <br />GIS Coordinates: X _, Y_ Township <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />(I NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) o DESTRUCTION (choose type below) <br />p SOIL BORING # [] OVER -BORE <br />$WELL# MNJ-� - (N a PRESSURE GROUT <br />*Other: <br />COMMENTS: <br />TYPE OF WELL <br />IDMONITORING <br />U EXTRACTION <br />[] VAPOR <br />[] AIR SPARGE <br />[] SOIL BORING <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? n YES ONO WELL CASING DIA: � <br />p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING O STEEL 0 PVC [] OTHER: <br />fl MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: (I AUGERS [] HOSE <br />0 PUSH POINT GROUT SEAL PUMPED: [l Yes n No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />[] HAND AUGER GROUT SPECIFICATIONS: _ <br />[] OTHER: p OTHER APPROX. BORING DEPTH <br />*COMMENTS: <br />CONDUCTOR CASING PROPOSED? <br />r \L � \ON -1 <br />U BOLTED TRAFFIC BOX or [] STOVE PIPE <br />( If YES, list specifications here): <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 Ordinanc les jqtions, and all applicable California State Laws.I,/ <br />Signed x y TitlelCompany �i `�" ' r' C' `Y <br />Print Name r�J���` et lA �� Date Z t/ <br />SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: „ / <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS I CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date <br />Date Issued � <br />Final Inspection By CUlliAIJ <br />I% <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # R 'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />CEPC89b69Z 95:ET <br />.ov�Z <br />306( <br />C-57_ WC; WAIVER_ <br />C-57 Lett erof AuthorA&VIO sign permit_ <br />Encroachment doc <br />9/27/00 <br />E8 39V6 <br />�007A H1�I_d �/ <br />CEPC89b69Z 95:ET <br />TBOZ/8Z/Z© <br />