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PAYMENT <br />RECEIVEC, <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />290 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />r <br />�In­nr hart + <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <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 />+' Q �n7 G�. Assessor's <br />WELL Location 5gs M vrleT �gerrss Street City J�L I[ Zip /a�GParcel# <br />rf�EXPROPERTY Owne Address 0510 14L Ci Zip ty �1 '�"* w7 Phone# '7 <br />1 <br />C-57 Contractor ��C / �?S <br />ddressr �/� r �'�� ip�Lic#hone# <br />Consultant / Sub Contractor AC -76 -S-ah-)e, Address City Lic# Phone#. <br />GIS Coordinates: X , Y , Township Range <br />Section <br />WO 1C TO BE PERFORMED: <br />EW WELL / BORING ( CPT EOPROB YDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) -,�' <br />RING # 0 OVER -BORE <br />0 WELL # Z, 0 PRESSURE GROUT <br />"Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />]MU ROTARY <br />0 AIR SPARGE <br />USH POINT <br />,,0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_ <br />_0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE �� MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL_C TREMIE TYPE TO BE USED: GERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 NoD <br />` NOTE: MAXIMUM FREE- LL DEPTH IS 30') <br />GROUT SPECIFICATIONS: /` Cl'� I&Iel ( <br />��11 <br />APPROX. BORING DEPTH T� Z ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CAS NG PROPOSED? ( if YES, list specifications here): <br />'SC S j kI <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 Ordinances, Rules and Regulations, and all applicable California State Law . <br />Signed x tddt.t/ / Title/Company t- � /� <br />PrintNama G� 1 _ Gt Date 7— / —Z) j <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /'.9 <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date <br />/6,3-oi <br />Inspection By <br />/.1 <br />ONLY: AID# <br />kAC,COUNTING <br />CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK# <br />REC'D BY <br />DATE PE ST # <br />INVOICEa� <br />s��` <br />`�t� 6`� <br />C-57 ✓ WC ✓ -WAIVER C-57 Letter of Authorization to sign permit t=ncroacnmenT CIO 9" 7/ C-1 <br />