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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />a 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />s f ° '`' (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />kpplication 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 \\S NqQ— Cross Street cityZip -zY334 Parcel# Z- 9 1 ri 1 <br />°ROPERTYOwner �-A�r�crt,c. Address—D O LJx \O ZZ City �o+�.�tccq Zip 5336 Phone# --3`t- 1-\l`i 1 <br />a VJ Y k3 Q u��`�o Cit2 Zi Lc Phone# <br />C�7 Contractor �\� � ^Address Y P <br />_ c�s <br />City�o. Lic# Phone# Z U`t S 2-2. <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED,- <br />NEW <br />ERFORMED:NEW WELL / BORING ( CPT, = PRO YDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />I SOIL BORING # G P Z F 3 OVER -BORE <br />a WELL# PRESSURE GROUT <br />"Other: Grout Specifications: <br />COMMENTS, <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />a MONITORING <br />%HOLLOW STEM <br />DIA. OF BOREHOLE <br />MULTIPLE CASINGS? j] YES ONO WELL CASING DIA: <br />U Ek i RACTION <br />0 AIR HAMMERtDRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: O STEEL O PVC []OTHER: <br />0 VAPOR <br />fl MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />0 AIR SPARGE <br />8 PUSH POINT <br />GROUT SEAL PUMPED: I] Yes <br />11 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />if SOIL BORING <br />a HAND AUGER. <br />GROUT SPECIFICATIONS: <br />0 07H=R: <br />I] OTHER <br />APPROX. BORING DEPTH <br />t) BOLTED TRAFFIC BOX or 0 STOVE PIPE - <br />'COMMENTS: <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />c <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, uleAwdft gulatio and all applicable California State Laws. <br />Signed x (� Title/Company n*`�� <br />Print Name \�0.� Y� 1 c l�O �a �`�`�`! Date Z y <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: % S / W L o v i re Ma n h� <br />WORK PLAN DATED: �P/�2 z 2,0()3 <br />Application Accepted By C r i ct ' 1 r r Date Issued t 3 .Z 004 Area % 4S9 <br />Grout Inspection By Date -5 Final Inspection By ate <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: ►' Co Y r -2 <br />ACCOJN T ING ONLY: <br />AID#, <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE EST # INVOICE <br />35-0 1 <br />89.00 <br />89.00 <br />015903 <br />0037 38 <br />C-57_ WC= WAIVE,?_ C-57 Letter of Authorization to sign permit_ 9/27/00 <br />E8 Ecv1d c007 -d H1dIA EEbE89bE0Z 99:ET T907/8Z/Z© <br />