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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 />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 />IU --S -ZV-r"'a-"loll Assessor's <br />WELL Location 2 15 Q. IMa, A 1?,, Poyj C6 Cross Street Lo c-uS't City R"00")_zip 953" Parcel# <br />PROPERTY Owner I�it vl Vo A -Ds 1t ejn Sr- Address Z 157 W, I/1� , V\ S i City (Z; �Jo/1 Zip q 53(4Phone# ??1o`(15 -J2 3 y JAL <br />Va.IItN <br />C-57 Contractor r,srk E:,A Address 5her115 PIa(—C- CitySorT,rgsZip95Z571ic#L8386S Phone#Za4.)-772.-3570 <br />Consultant Sub Contractor ATC- A SSoc-- Address 1/17 LoHc Palm # g City cs Lic# <br />GIS Coordinates <br />91 <br />Townshi <br />Ra <br />Phone# 219 579-27-2—j <br />Section <br />WORK TO BEPERFORMED: <br />NEW WELL BORING ( CPT, GE PROB YDROPUNCH, HAND -AUGER, OTHER-) [] DESTRUCTION (choose type below) <br />SOIL BORING # SB-- 5B 13 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />"Other: Grout Specifications: �e Iv jo h GrO�lk <br />COMMENTS: <br />TYPE OF WELL <br />[] MONITORING <br />[] EXTRACTION <br />[] VAPOR <br />[] AIR SPARGE <br />'SOIL BORING <br />[] OTHER: [] OTHER APPROX. BORING DEPT <br />INSTALLATION TYPE <br />[] HOLLOW STEM <br />[] AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />PUSH POINT <br />[] HAND AUGER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE '-2-11 MULTIPLE CASINGS? 0 YES [INO WELL CASING DIA: <br />NA - <br />CASING THICKNESS NR TYPE OF CASING: [] STEEL [] PVC 0 OTHER:_ <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />S, 1 00 [] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?- AJA( if YES, list specifications here): <br />'COMMENTS: 6 bogy 1 n s -t-o 2- 1 f 1 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REUUIKLU INSrt_G I IUNJ. <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, Rulleesl and Regulations, and all applicable California State Laws. ,1 <br />Signed x/_� (��pvy� �— o'�Oyri4pM t Ti • Title/Company BtSSOC Tt c <br />S�o�vlvy �on Scy <br />Date— <br />Print Name �D I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted E <br />Grout Inspection By_ <br />Destruction Insoection <br />!`/1AA11ACA1T42 1 (`nMn1T1(1WC• <br />Date <br />Date <br />C <br />Date Issued I I (� \ Area I <br />nal Inspection By <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />L4 <br />SR# <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit Encroach ent doc_ y/ciivu <br />