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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ti <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT 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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Stanriards of San Joaquin County Public Health <br />Services, Environmental Health <br />Division. <br />5tAssessor's <br />CiParceWELL Location 212-8 u Zis l#.236{ <br />(D%p j <br />PROPERTY Owner rP'J(�Lu Address V� 71 ) 4 142(M9 Cih Zip /7,��;3 Phone#7�yj <br />C-57 Contractor CCS S c c. J e ddress �W l.(. dWI � L � �,L, 1Cityr <br />:01f %j0 Phone# L j�( <br />Contractor <br />1 Vii/W <br />Consultant / Sub Contr"�> � VIN ul Address d } ,)[,�!L City�a Lic# Phone <br />17 <br />GIS Coordinat cx (0,`>I lfr �� J Y 90 1 i LH , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT <br />*Other: <br />COMMENTS: <br />TYPE OF WELL <br />;(MONITORINGZ. <br />Q EXTRACTION <br />VAPOR <br />:OPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />JIL 130IG # 2- t+:p 0 OVER -BORE <br />ELL # Z Iu 0 PRESSURE GROUT <br />Grout Specifications: <br />INSTALLATION TYPE <br />(HOLLOW STEM <br />0`AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />Q AIR SPARGE 0 PUSH POINT <br />p SOIL BORING HAND AUGER Z ^ <br />0 OTHER: 10 OTHER <br />'COMMENTS <br />0', <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 6" MULTIPLE CASINGS? BYES 0O WELL CASING DIA: 211 <br />CASING THICKNESS TYPE OF CASING: 0 STEELVC a OTHER: <br />DEPTH OF GROUT SEAL % 1C) TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes Jj No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) O <br />GROUT SPECIFICATIONS: 1 Gr?►�+e✓1 <br />APPROX. BORING DEPTH `. 'g BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? lv '( 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 INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print N <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />22- fsi� �So� <br />Date <br />Inspection <br />r <br />J <br />C <br />ACCOUNTING ONLY: AID# cer�e <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY DATE PERMIT EST # <br />INVOICE <br />Z o z-5 D.3 -C) <br />C-57 V WC -WAIVER C-57 Letter of Authorization to sign permit -!L -Encroachment &C � 9/27/00 <br />