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WELL PERMIT APPLICATION FOM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 />l Assessor's <br />WELL Location L�In �/L f Cross Street f City Zip Parcel# 65- 5 —L) z. 0 <br />PROPERTY Owner* V /VVYAVI A 4 G-\ W(✓lAddress , ' � � �' US— <br />Ci "T i C] �1�� Zip -`I l Phone# M?5 OOL Z -Cius <br />C-57 Contractor l �'7� Gv J f , Address j� j C C• `(� Cityrcrl ��� ZifO5 fl l�.ic# � 1 IQPhone / Q{��r/�) <br />Consultant /Sub Contractor '' ( Q f � � j' l�dress 3 t l � � 1c, L"C'c - Ec) City �� ° a Lic# Phone# I cl I � Cko I' O y w <br />GIS Coordinates: X Y ` Township V Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) I DESTRUCTION (choose type below) S <br />[] SOIL BORING # I OVER -BORE <br />0 WELL # Grout Specifications: PRESSURE GROUT <br />`Other: j l_ f�/lJ l_( I�LNc. 'i <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: c <br />VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE . <br />Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br />n OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED 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 Or finances, Rules and Regulations, and all applicable California State Laws. <br />Signed x ICA�'--'- Title/Company` <br />Print Name (. )0 of t1,,(vl �L'1 Date <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / CONDITIONS! <br />DEPARTMENT USE ONLY <br />Date <br />'A Uz lrika, A <br />, 100. / /� zoo <br />ssued <br />Inspection By <br />S <br />ACCOUNTING ONLY: AID# cer`�e <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DAT QUEST # <br />INVOICE <br />�. <br />C-57 WC -WAIVER C-57 Letter of Author`iz r,' sign permit`'-- _�ncroachment*c 9/27/00 <br />