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WELL PERMIT APPLICATION F .,RM SITE <br />PE CODES <br />MITIGATION <br />AMOUNT REMITTED <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />REC'D BY <br />��Y)-3 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />PERM QUEST # <br />304 E. Weber, Third Floor, Stockton, CA., 95202 e <br />EPvV 11 ES (209) 458-3449 <br />NON-REFUNDABLE PERMrr 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 />I l Assessor's <br />14-�n �• blQ CrossQStreei:3 City Zips <br />WELL Location • _Parcel#_ <br />1 <br />PROPERTY Owner ���fJJS� _ Address U� (�I Qp��1Mo U� __citY Zp_gf3 a Phone# <br />11n�,)�I(. <br />C-57 Contractors "i Ct0.� Address 3ZZ City l{�ic# Phone# ,-(2� -7t <br />! 1c�ip <br />1 S City Liclf%_Phone#� <br />Consultant l Sub Contractor H UA ss <br />GIS Coordinates: X 'Y Township Range Section _ <br />WORK TO BE PERFORMED: <br />;ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) p DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />--WELL # l'llt�-�_ o PRESSURE GROUT <br />� <br />"Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Z <br />AMONITORING HOLLOW STEM DIA. OF BOREHOLE � f � -- MULTIPLE CASINGS? I] YES %tN0 WELL CASING DIA: _ <br />EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 1] STEEL S PVC 0 OTHER: <br />[] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: DAUGERS 1] HOSE <br />0 AIR SPARGE () PUSH POINT GROUT SEAL PUMPED: 0 Yes 4j�No (NOTE: MAXIMUM FREE -FALL DEPTH 1S 30') <br />0 SOIL BORING 1] HAND AUGER GROUT SPECIFICATIONS: - <br />APPROX. BORING DEPTH Z� / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />7) <br />0 OTHER:_ -] OTHER <br />CONDUCTOR CASING PROPOSED? D ( if YES, list specifications here): __ <br />) <br />'COMMENTS: A <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 />1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or an s, les and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 1 �0�0' <br />V <br />11 ff Date (0 (2a - <br />Print Name Ll..lQ W ('P `Pv <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued I r G I Area <br />r C ( Final Inspection B c G� Date_ <br />Grout Inspection By Date / � /I��wLr'c.�-� Y <br />Destruction Inspection By Date <br />QTc i enummoNs• <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERM QUEST # <br />INVOICE <br />C-57 WC= WAIVER C-57 Letter of Authorization to sign permit✓ c_ 9/27/00 <br />