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WELL rtRMIT APPLICATION F=ORM SITE <br />TION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />IV <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 Sar, <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />N4 g Assessor's <br />WELL Location Z(S W. iYlat A 5-tv-cx-+ Cross Street Low S f City R.o r\ Zip 95366 Parcel# <br />PROPERTY Owner ?au` Vo h lbu V ­e o Address Z15 W MckiA 5t CiZip 95364 Phone# 599-3yf5io <br />Valles I <br />C-57 Contractor 'F'isc.ln EA14COA t'teNkaiAddress -YM 5�...v-i's P1as, City `'�'�'� Zip9��-Lic#483i1GS Phone# Zo9 -7777--3570 <br />C-57 <br />/Sub Contractor A L ASSOG Tin` Address ) l l-7 Long Qo-� vin B City f� ooUs-tb Lic# Phone# S'79 <br />GIS Coordinates: <br />Y <br />Township <br />WORK TO BE PERFORMED: <br />`, NEW WELL EOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />SOIL BORING # <br />0 WELL # <br />'Other: <br />CnMMFNTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />`KOIL BORING 0 HAND AUGER <br />0 OTHER:_O OTHER <br />'COMMENTS <br />Grout Specifications:. <br />Range Section <br />` <br />0 DESTRUCTION (choose type beIV) <br />AMOUNT REMITTED <br />0 OVER -BORE <br />REC'D BY <br />0 PRESSURE GROUT <br />PERMIT 1 SERVICE REQUEST # <br />INVOICE <br />356 1 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE e- 2-1I MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: IV 14 <br />CASING THICKNESS N Pr TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: Al 4 <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH /DO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? IV & ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INsrtU I IUNZb. <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, Rulesand <br />Regulations, and all applicable California /Spate Laws. <br />Signed x (^f / 6I�� T';tle/Company ITT C- ftS50U AtG S .� N G — <br />Print Name Date ��d I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD <br />WORK PLAN DATED: S <br />Application Accepted <br />Grout Inspection By - <br />U <br />)-Is /I' - X; <br />.v0 Date Issued � a c ( Area. <br />Date ,S Final Inspection By Date <br />Destruction Inspection By CJ Date <br />rn11,1MFWrc 1 CONDITIONS' - <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT 1 SERVICE REQUEST # <br />INVOICE <br />356 1 <br />5 <br />a-�3 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign per Ln � <br />S�oo2- <br />�13�1� <br />