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WELL PERMIT APPLICATION FOKM SITE <br /> t �I,T�vTION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER I <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-E <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 /> WELLLocation ��" �yQ Cross Street City S\_CjtV^�� Zip 15Z"Zy Parcel# <br /> PROPERTY Owner Ozz�,Aw �v`} _Address P-c•8Dk T�13 1C04 City 5c%- d`eNQ Zip'M00 Phone#(014 5L8- M3 <br /> C-57 Contractor W ac���►.l� r� ��"����^+4 Address -53 b City lk`a��1k Zip Qv15� Lic#x-100" Phone#43 3*y-`i3�Q <br /> Consultant/Sub Contractor V-1--7(_ A-`s Vo `-. Address R11(1 Lja%L�Uv^ *6 City k--� Lic# Phohe#2.0 <br /> GIS Coordinates:X 'Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type beloW) " <br /> 0 SOIL BORING# 0 OVER-BORE <br /> /ELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE(0-15 N MULTIPLE CASINGS?)YES ONO WELL CASING DIA:1 -(4 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-S 61+L{�3 TYPE OF CASING: 0 STEEL eVC 0 OTHER: <br /> )�VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 15 ' TREMIE TYPE TO BE USED: GAUGERS CHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: - oTk r <br /> ), OTHER:P�I. 0 OTHER APPROX.BORING DEPTH �0'�^ B�� tSOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances <br /> / Rules and Regulations, and all applicable Californian State Laws. <br /> �A /� (� <br /> Signed x AL V Q,�`'� - Title/Company 4 �J t t)- /�W� ( " " T1✓ _ " '3)oca4j <br /> Print Name 't"i Q,`V,. �` Date �`tilde <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 325- <br /> WORK PLAN DATED: 6 Lz <br /> Application Accepted By _Date IssuedI O Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE ;ST# INVOICE <br /> o / �9 S�0� Oo 2 G 2-535 <br /> C-57 WC=WAIVER_, C-57 Letter of Authorization to sign permit EncroacitYtrent day" 9/27/00 <br />