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I <br />WELL PERMIT APPLICATION FORM <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 />Assessor's <br />WELL Location AP Cj r Cross Street A--StU City S4•Q(K4-c-^ Zip YLt Parcel# <br />o i4 Q. N Address pJ ��. 1,0 t,0 Ci Zi 7Sy� I Phone# t( (o`O 3 <br />PROPERTY Owner ���.n, ty P <br />�Uc�Jv�G �^. x 33 Ci Qt��U1. Zi y- SL1 Lic#-7-f��"l Phone# <br />C-57 Contractor t, Address h/ P <br />k—k L Address I II -T �— 1Oal, 15 Ci /j2E' >o 4 Lic# Phone# 9 LZ z I <br />Consultant /Sub Contractor- tY <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />' <br />VEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, <br />HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type beIV) <br />0 SOIL BORING # <br />0 OVER -BORE <br />',�R'W ELL #_WIA)-- <br />, AM 17& 0 PRESSURE GROUT <br />S <br />'Other: <br />Grout Specifications: <br />r� <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />Z <br />ONITORING <br />�rHOLLOW STEM <br />DIA. OF BOREHOLE `e MULTIPLE CASINGS? 0 YES ` 10 WELL CASING DIA: <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS5L� TYPE OF CASING: a STEEL }-PVC G OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 5() -t TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: RYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />0 OTHER:_O <br />OTHER <br />APPROX. BORING DEPTH'FZ- tt' b<SOLTED 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 REQUIRt1J INblat_(; I IUNZ). <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, R les and Regulations, and all applicable California State Laws. A <br />Signed x /t} ^� � - - Title/Company 'K_2 �� J <br />Print Name �� ��"'� � "� " � Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED: <br />Application Accepted By Date Issued ?r'1 ' i5Y _Areae <br />Grout Inspection By 1 A l A ;wwtn Date a Final Inspection dy I (Awwt Date <br />Destruction Inspection By Date <br />COMMENTS /COND <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P EST # INVOICE <br />3Sol <br />sq c) l�'I <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign mit Encroachment c_ 9/27/00 <br />