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WELL PERMIT APPLICATION FORM <br />nECOVET MITIGATI®N <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />JUL 3 p 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIROHtViEf�T HEASTH <br />(209) 468-3449 r� U <br />S <br />�FRM�iISE NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 <br />Applicatio is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made •n compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental ealth Division. <br />` -u� ! /� - ' �� Ass sor's _ <br />WELL Location LC/n� �[ . ss street S�("��7G+� City >%C�zd �! Zip !� 2U� Parcel `(%- 1(U(> - <br />PROPERTY Owner Y '�7 ( �L I -d - ?1 -Address 2-3t' 3 " �-/ C14)ACityS /cX (C�c zi S 20 Phone# G <br />/ � 1 <br />C-57 Contractoi(Y�4f DCt L& l r Address ,rD �OZ✓� L� City A ---w Z Zio$� 3 Lic# f Stq � Phone#� <br />Consultant /Sub ContractorurWd-'2 �iC nLUj&sdM A[TACAddress Phonel ��4 -006 <br />GIS Coordinates: <br />Township <br />WORK TO BE PE MED: <br />NEW WELL / ORING PT,' EOPROBE, HYDRU � H HAND -AUGER, OTHER') <br />JXSOIL BORING # <br />0 WELL # <br />'Other: T Grout Spe <br />n <br />r-r)ftA P T¢ <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HCLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER _ <br />'COMMENTS: <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />OVER -BORE <br />PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Z MULTIPLE CASINGS? 0 YES 4NO WELL CASING DIA: A <br />CASING THICKNESS_ _ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL�7ALrl( TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />GROUT SEAL PUMPED: kYes p No (NOTE: MAXI UM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ' %Ja� — <br />APPROX. BORING DEPTH t7� a BOL ED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_ QD _ (if YES, list specifications here): <br />(;7 vF 1"14 S, i�6ivA�(G� <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 />1 hereby certify that I ha <br />County Q"arj"s � <br />Signed x <br />Print Name r� <br />prepared this application and that the work will be done in accordance with San Joaquin <br />and Regulations, and all applicable California State Laws. <br />Title/Company-S/p/�T/�uCa/���C�L <br />>� Date � J/�7/� % <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDR <br />WORK PLAN DATED: <br />Application Accepted By <br />MM <br />,; <br />Date Issued <br />Q Area <br />Final Insnection By /" 1 t_ Date " �✓ d2" <br />C-57 WC '-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment clot_ yl e //Vu <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />C-57 WC '-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment clot_ yl e //Vu <br />