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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 />ORIGINAL <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 />NELL Location �L�` ul�Th\ (� Cross Street, ll\'_City}C.k� Parcel# t- <br />13ROPERTYOwnartea" C Address �� ��0.�' �1y,'jCity�\�, S Zip�l'<<'t'Phone# <br />�)u )oo-D <br />� �i <br />C-57 Contractor �t �f�i � � Address , J `). �� �a City Zip<�Phone# <br />Co`, nsultan.'/ Sub Contractor \: , CoLq <��n,cArldress ��� 1 l �� City I 5 'Lic# Phone# Z S� ]-y �1 `lll <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED:_ <br />> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) j] DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE <br />V WELL # 4 [] PRESSURE GROUT <br />*Other; Grout Specificatiops: <br />c. <br />COMMENTS: \> � � \ ti' s r �� s 7, 0 y A <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING U HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? ]]YES ONO WELL CASING DIA: <br />j] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL [] PVC [] OTHER: — <br />11 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />[] AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: [] Yes j] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />j] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS: <br />[] 07HER: j} OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( If YES, list specifications here): <br />*COMMENTS: \� ,' \L V O <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordi es, R les d Regulations, and all applicable California State Laws. <br />Signed x 9. TitlelCompany <br />9 <br />Print Name ;Y`��^- Y _Date `-1 — �— <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADI <br />WORK PLAN DATED: fin, <br />Application Accepted By Date Issued L5�1� Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# S L%v L160 , <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT 1 SER =EST # <br />INVOICE <br />C-57-___ WC --WAIVER <br />C-57 Letter of Authorization to sign permit <br />A Encroachment doc <br />9/27/00 <br />�d007-d HiAIA <br />8EbE89b69Z 95:ET <br />ZB©Z/8Z/Z© <br />9-> <br />