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-ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />MITT 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 />%pplication 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 />p / >� j • Assessor's <br />NELL Locatiol 2-90 / 1. A,47 -/ 4✓ / Crass Street ,A 15 City I ` �^c���-� Zip � S 33 b Parcel# <br />?ROPERTY Owner !3 Address �' (�Q ntkr City zip 9533-1 phone# Z3—Sy �Q <br />—tZb9J`i <br />C57 Contractor a ���•�k Address P Qo� �l\O City S\A+-- Zip°[Sl`�l Lic# Phone,# 9)b �� P ��10 0 <br />"r Address >>') City_ o,0io Lic# Phone# iLZ' <br />4�1� <br />GIS Coordinates: X <br />Y <br />Township <br />WORK TO BE PERFORMED: <br />{] NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />[] SOIL BORING # <br />t W E LL # rl,w 5 d Yv-NVJ <br />*Other: --_Grout Specifications: <br />COMMENTS:AtAeuAtA­ <br />TYPEE OF WELL <br />INSTALLATION TYPE <br />16MONITORING <br />it HOLLOW STEM <br />Q EXTRACTION <br />U AIR HAMMER/DRIVEN <br />[] VAPOR <br />Q MUD ROTARY <br />[] AIR SPARGE <br />G PUSH POINT <br />[] SOIL BORING <br />0 HAND AUGER. <br />[] OTHER: <br />{] OTHER <br />Section <br />1] DESTRUCTION (choose type below) <br />0 OVER -BORE <br />[] PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: [] STEEL D PVC []OTHER:__ <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />GROUT SEAL PUMPED: [] Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH _ 0 BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? <br />OSED? (if YES, list specifications here): <br />*COMMENTS: S � P\) \) "�� t '7 — 1'�'- '0 q <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 />I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules dd Regulations, and all applicable California StateLaws. <br />p TitlelCompa r y <br />Sianx __ ) <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD -USS: �� N • Q'``` <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />Cr)MMFNTS I rONDITIONS: <br />Date <br />Date <br />I Inspection By <br />i� <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />i <br />FEE INFO , I AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE�dd� RVICE R <br />INVOICE <br />1X <br />g 2- <br />4 <br />S RtD <br />C -57 --it WC-Vr -WAIVER_ C-57 Letter of Authorization to sign per4it V' ncr aC9/27/00 <br />Eta 391v6 � EEbE89b60Z 95 ET TOOZ/ /Z© <br />