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WELL r-ZRMIT APPLICATION Ft,,.iv1 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202,. <br />(209) 458-3449 <br />*' W - <br />NON -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Rl�t <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 />< i. ,+ Assessor's <br />WELL Location �I U ` �-'+) .I f_ l em P.04 Cross Street Lj i1 a City S cc K % i % Zip Parcel# <br />PROPERTY Owner V 1 b �' f Q vim• I Address flI P to �- l+9 7 �< ►.1 5') City S I u� K a_,, Zip 'j905- Phone# � C' <br />C-57Contractor A G Address Y 7 5r4t1 �y.i0 CityS ry<KI'^: �Zip���21 LIQ vCZ?Phone�ltw' �/No % <br />Consultant I Sub Contractor PLY Address l i 7 S /1 �i W kr a'oCity > i �� ". �Lic# 7Phonef�� <br />SITE <br />MITIGATION <br />UNIT ISI <br />GIS Coordinates: X _, Y , Township Range Section <br />WORK TO BE PERFORMED: //--�� <br />EW WELL/ BORING ( CPT,�(ac.OPROgEINYDROQ}JNCH, HAND -AUGER, OTHER-) <br />7SOIL BORING # f b <br />/OkWELL # � <br />'Other. <br />/-nh AA ACAITC• <br />Grout Specifications: • i ' "'' � <br />0 DESTRUCTION (choose type below) <br />Q OVER-13CRE <br />Q PRESSURE GROUT <br />+ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />o MONITORING I] HOLLOW STEM DIA. CF BOREHCLE '2 " MULTIPLE CASINGS? 1] YES Q NC WELL CASING CIA:- <br />--a EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESSwjf'-�-_ TYPE OF CASING: []STEEL [] PVC O OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL • � �X _ TREMIE TYPE TO BE USED: o AUGERS AHCSE <br />Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 1] Yes Po (NOTE: MAXIMUM FREE -FALL DEPTH IS 30'1 <br />gSOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: PL i �'i+t�li�✓1� <br />a OTHER: ] OTHER, APPROX. BORING DEPTH ��-� � (] BOLTED TRAF=iC BOX or [] STOVE PIPE <br />'l CONDUCTQ CASING PROPOSED? I-110- (if YES, list specifications here): <br />'COMMENTS <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT Phf<Ml I ZZ). <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, Rules and Re ulations, and all applicable California State Laws. <br />TitlelCompany L �� a/ P� A. G- <br />Signed x_ --L-- <br />Print Name 1 / (- V r- L ` T'� Date V� ��3! 0 � <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: - <br />WORK PLAN DATED: <br />Application Accepted By <br />Date Issued Z- Area - <br />Grout <br />Area <br />Grout Inspection By Date / 2 Final Inspection By Date _ <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />II <br />ACCOUNTING ONLY: AID# S��rrJ i, CJ t <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />RECID BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />I INVOICE <br />l <br />g9� <br />/G�oG <br />l<7 <br />Z l <br />n,7 H`10 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/2 <br />