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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ORIGINAL <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 />li�-..sk S Ck9-- 2 4-t, W\&tO- So�'.kh -F Assessor's <br />NELL Location F'�.1,\cc l�k\ " ,�Qr o F °�o Cross Street Nt1''\�. S�ra�CCity� �CC� Zip �S 33 Parcel# <br />!GDW --d. c-- N <br />PROPERTY Owner O¢C\�� ��� � rd o z -o. Address P 0 i� ��c I 0 Z Z C,it1y � �e,� Z S 3 3 b Phone# <br />C-57 ContractoryU//���1��� //"t�,, Address76274 <br />/Ply Q s Cit}+�W V Zip SZ[ Lic#� Phone# <br />Consultant 1 Sub Contra ctod:JLCwut e'&' / Address City`W, Lic# Phone#��� (� <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />FEE INFO tAMOUNT REMITTED <br />%NEW WELL/ BORING ( CPT GEOPROBE HYDROPUNCH, HAND -AUGER, OTHER-) [] DESTRUCTION (choose type below) <br />G # S �r !�\�,�,,�C­% 'k P ro s, k� [] OVER -BORE <br />REC'D BY <br />DATE T 1 SERVICE R <br />INVOICE <br />[] WELL # Q PRESSURE GROUT <br />1 <br />'Other: Grout Specifications: <br />COMMENTS: <br />�� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U MONITORING 11 HOLLOW STEM DIA. OF BOREHOLE < yti MULTIPLE CASINGS? [] YES t NO WELL CASING DIA: <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL p PVC [] OTHER: <br />Q <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEA71,%'25' TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />1 <br />0 AIR SPARGE ® PUSH POINT GROUT SEAL PUMPED: N Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />V SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br />p OTHER: [] OTHER APPROX. BORING DEPTH 26 [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br />(� <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 />San <br />I hereby certify that I have prepared this application and that the work will be done in accordance with Joaquin <br />County Ordinances, Rules Regulations, and all applicable California State Laws. <br />A K � � Title/Company <br />Signed x 2 ` <br />Print Name 0�'J `r^,--,) i Date 3 <br />DEPARTMENT USE ON�L/Y <br />SITE MAP IN UNIT IV FILE, ADDRESS: o N. ,� �� /t� <br />WORK PLAN DATED: N' �S -O/. oC f- ZZ • O/ <br />Application Accepted By Date Issued <br />-0 Z— <br />Grout Inspection By Date Final Inspection By <br />-_ <br />Destruction Inspection By Date <br />3' L 2.0� S•� • 0 <br />COMMENTS /CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO tAMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE T 1 SERVICE R <br />INVOICE <br />35or <br />•� � <br />��-3z3 <br />� z' ODzs�3 <br />�� <br />C-57 WCC WAIVER <br />C-57 Letter of Authorization to sign permit_roachment doc 9/27/00 <br />Ee 39d6 2100 -`IA HiAIA EEVC89VGOZ 9S:CT ieeZf8Z/Z0 <br />