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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) 4683449 <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 />/��L1. Assessor's <br />WELL Location L H '411,44J. <br />97i1J � Sj7D0 CARL &'Gross Street j:AS% rnDL City T/thCZip Parcel# <br />(7DSL PROPERTY Ownerlll:%St 0kS1'^/4✓ir1`-' ' ?Address DOtJ-•40M5, City Zip Phone# 205'$3�j'//2� <br />C-57 Contractor ttit% Z 4— Address JL2.5 /=i}Z[Eltelt4 A4 City�i--'! Zip?Lic# ss'y175Phone# i!4-- (-3 B "%2 % j. <br />Sa/r`�✓ Ed 1- Address VOOS' C��e Ito /-�� � 2 L3 0 <br />Consultant! sub Contractor city o� 'Qin Phone# % 'Z8�- <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') W61ESTRUCTION se type below) <br />0 SOIL BORING # OVER -BORE <br />WELL # n PRESSURE GROUT <br />"Other. Grout Specifications: �D/t.%C 7 -ZZ <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE <br />MULTIPLE CASINGS? 0 YES [I NO WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br />p VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />_ <br />TREti11E TYPE TO BE USED: 0 AUGERS 0 HOSE <br />[I AIR SPARGE <br />[I PUSH POINT <br />GROUT SEAL PUMPED: <br />n Yeo No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: <br />n OTHER: 0 OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or n STOVE PIPE <br />'COMMENTS: yL4141—t-ic/— <br />CONDUCTOR CASING PROPOSED?(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 1 have prepared this <br />County Ordinanc�, Ryes andjRegulath <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Weation and that the work will be done in accordance with San Joaquin <br />and all applicable California State Laws_./ <br />Tide/Company_ !'✓'�-st'' /T''►2.M�-c.4Ja <br />0 <br />SE <br />9-ZO-oz. <br />Applicadon Accepted By /fo f -'s Date Issued q �� Area C� <br />Grout Inspection By Date Final Inspection By b Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE M713ERVcST # INVOK:E <br />-o <br />C 6b- <br />'C33� <br />'/C+'�-- <br />��zI Z <br />-Z)/_ VVG WAIVt:R_ <br />C-57 Letter of Authorization to Sign permit acumen 9/27/0p <br />Z0 39Gd dOO-d HiAI3 ££ti£89b60Z TZ:TT 0002/TT/ZT <br />V% <br />F <br />