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HE <br />'KNELL- PERMIT APPLICATION rjRM SITE <br />CVMFP" MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />OCTA I ZOO ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONfMEW F11EALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (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 Tide, Chapter 0-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />n — p Assessor's <br />n <br />WELL Location i' �� r"I U4 Cross Street v City Zip lS 3 Parcel# _ <br />PROPERTY Owner Cj- - \ U 0 Address (Do 1 �1( 1 -S _City V CA = re` _Zip ! S;33? Phone#f <br />C-57 Contractorl&,,- <br />J�nn Address <br />Consultant / Sub <br />c#Phone# '%3E 7270 <br />Lic# Phane# 4Lj- I n n <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />,a -NEW WELL /BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) NSOIL BORING # 0 OVER -BORE <br />�NELL #—�k� PRESSURE GROUT <br />'Other: i Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />-kMONITORING <br />OHOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />SOIL BORING <br />n HAND AUGER <br />CONSTRUCTION SPECIFICATIONS 11 <br />DIA, OF BOREHOLE' MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA:__ <br />CASING THICKNESS TYPE OF CASING: []STEEL PVC 0 OTHER: (` <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: RAUGERS 0 HOSE �\ <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 GROUT SPECIFICATIONS: - <br />0 OTHER:_ p OTHER APPROX. BORING DEPTH - i _ o BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N n (if YES, list specifications here): <br />r[U r <br />NOTE: OFFSITE BORINGS REQU1 E ACCESS OR ENbROACHMENT PERMITS.' C-0" 44 <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 OrglinpnFes,(Rules and Regulations, and all applic�k'- rMtif..rr,ia Statp f aws_ <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 0 Area <br />Grout Inspection By­� Date 0 i Final Inspection By ca Date Z s t7 y <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERM <br />INVOICE <br />�Scf.oc� <br />I S�S3$ <br />(0 2Yo OOo�•+ `6f <br />C-57 WC= WAIVER C-57 Letter of Authorization to sign permit_nnCFdachment doc✓ y/ �� <br />