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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 />Sc>t1C(c� I� ��"" r' y Assessor's <br />WELL Location I-..tVI C col cj� VCross Street Ck"N /Ch` ` if- City 5+P4, �I ,94 Zip +5ZO42 Parcel# <br />PROPERTY Owner K c V 1 K 13,mI S 0 Address 1145 W. ck4lt 4ci ' V4,A %1 City *Oe — z?n Zip 115U O Phone# SsQ7oo Zo*-4-M2 <br />II f L 323' •F,f z5"YAI Ra ,ko C75��7q, <br />C-57 Contractor W� f-sT f1A=4111T- Address S wi en &�City i o✓jvy l ziP 15-142-Lic# Phone# Sl o 04 - v- <br />1552 be" --h s7t- F&I—Yv111G COM -707 <br />Consultant / Sub Contractor I C v� Address "A 1+ 4= City Lic# Phone# 5Z- 322Z <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />Township Range <br />Section <br />NEW WELL/ BORING ( CPT, GEOPROBE,YDROPUNCH HAND -AUGER, OTHER-) [] DESTRUCTION (choose type below) <br />0 SOIL BORING IiD- I Flv-Z. [] OVER -BORE <br />H WELL # [] PRESSURE GROUT (, ` <br />'Other: GROUT SPECIFICATION <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING <br />[] HOLLOW STEM <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />[] VAPOR <br />[] MUD ROTARY <br />[] AIR SPARGE <br />[] PUSH POINT <br />[] SOIL BORING <br />[] HAND AUGER <br />OTHER: ✓o Nnt [] OTHER <br />COMMENTS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES [] NO WELL CASING DIA: � <br />CASING THICKNESS TYPE OF CASING: [] STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: <br />GROUT SPECIFICATION <br />APPROX. BORING DEPT <br />TREMIE TYPE TO BE USED: [] AUGERS []HOSE <br />[] Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')In <br />-� <br />[] BOLTED TRAFFIC BOX or [] STOVE PIPE i <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State La and Rules and Regulations of the San Joaquin County. <br />* CALL THE IV INSPEC O 4 WORKING HRS IN ADVANCE FOR ALL (REQUIRED INSPECTIONS <br />Signed x Title/Company I CeS / pY IhC I Dal ! eh Alh t-G�' <br />Print Name eh eovl Date <br />SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By i'1 - ti Date Issued ! Area <br />Grout Inspection By 5ajy - SA�' Date t)Final Inspection By Date <br />Destruction Inspection By Dale <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />C <br />PE <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMI VtGE-REf21U # <br />INVOICE <br />CODES <br />C-57_ WC/WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 7/17/00 <br />