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• <br />WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <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 />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 />�_ C, /�, cl r Assessor's <br />WELL Location %"f To'—! S C. bA-Crosss StreetyrU Aoe• City JT Zip 21J Parcel# /' <br />PROPERTY Owner � 04 1 G a. Adddress, O �G%, /J��� � City °�-t'fn, Zip��Phone# q7o <br />C-57 Contractor_ (A �1JtCht 1 / Address `S 6 �"]Ol�ll.(c'r�_. _n7,ity ip � _ic#Yt��Phone# l?rs <br />Consultant / Sub Contractor AT - <br />Address ��l7 L� /'a ��+, City Lic# Phone# 1r,9—S <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />4p1EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) [] DESTRUCTION (choose type beIV) <br />[] SOIL BORIN� # 0 OVER -BORE <br />41ANELL # arA lM - 0 PRESSURE GROUT <br />'Other: MIL)-ICIA,g Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /-) <br />4IA4@� <br />NITORING FBLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 41 -NO WELL CASING DIA: - <br />0 EXTRACTION [] AIR HAMMERIDRIVEN CASING THICKNESS SC%) V6 TYPE OF CASING: [] STEEL 4.PVC 0 OTHER:- <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL SU'/Cr/ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE [] PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[] SOIL BORING [] HAND AUGER /GROUT SPECIFICATIONS: ,- <br />[] OTHER: [] OTHER APPROX. BORING DEPTH ?2-"116`1 *} BMTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?,da=j2 ( if YES, list specifications here): <br />'COMMENTS: " <br />NnTF- nFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PF-KIVII 15. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL KLUUIKtU INOrc� I IUNO <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or in/a�F­Q <br />nces,oF�"ulea�ntRegulations, and all applicable California State Laws. _( <br />Signed x /vTitle/Company <br />Print Name v vl � � Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: y O 7 S M a I't, St - 5 <br />WORK PLAN DATED: 1 <br />Application Accepted By <br />DatIssued L Area <br />Grout Inspection By �,l �at,�2- F—C Dinae l Inspection By �- Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />(n <br />A— <br />ACCOUNTING ONLY: AID# FA(�u <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER ERE ESZ <br />OICE <br />00 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 9/27/ <br />