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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 />npip[W <br />SIT <br />MITIGATION <br />UNIT IV <br />ON <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 />n 11 n' 1 <br />_tG Assessors <br />Z\O� <br />WELL Location QA E. _ Cross Street � v �\iY� QWCity Zip 1SZD Parcel#__ <br />04.o 4a:.b.,t r C �+ G <br />PROPERTY OwnerU&Utk'% 16 eaJu�� Adddrreess__� �\�r`r IDYL Qv� City- a tuff\ Zip �tyb$��3 Phone#=1 pyZ� !�- <br />C-57 Contractor _l� ��`� Address ISv_�;City niin�e� Zip 11%57)1 Lic# 7a�tb�Phone#S"313-$'�Op <br />, <br />Consultant I Sub Contractor S!J \n4eancZ�n�Address L1�.i �L foo City jCQLz,&zL_,_Lic#(o SyA99 Phone# 116-6�p1"O�OQ <br />GIS Coordinates: X Y <br />Township Range _ Section _ _ <br />WORK TO BE PERFORMED: <br />%j4EW WELL I BORING ( CPT, GEOPROBE, H ROP NCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />SOIL BORING _._ [I OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />pi' -CA p%r�wa�_ So;� �� Grout Specifications: _ Cer-� 'r <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />PE CODES <br />U <br />[] MONITORING <br />[I HOLLOW STEM <br />DIA. OF BOREHOLE -3" MULTIPLE CASINGS? Q YES /ANO <br />WELL CASING DIA 14t <br />O <br />Q EXTRACTION <br />[I AIR HAMMERIDRIVEN <br />CASING THICKNESS NIA, TYPE OF CASING: [] STEEEL\\ <br />[I PVC 1] OTHER: �31("'� <br />LJ-) <br />IJ VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z�� TREMIE TYPE TO BE USED:-XAUGERS 0 HOSE <br />AIR SPARGE r PUSH POINT GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: IJepk eer�q�- <br />5 <br />0 OTHER _OTHER D,rE& ?vdi`N APPROX. BORING DEPTH 'L.O 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE 4 - <br />CONDUCTOR CASING PROPOSED? N he (if YES, list specifications here): <br />*COMMENTS: - <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 OrdinanraSRulep and Regulations, and all applicable California State Laws. <br />\ <br />Signed x_ r�j1� Title/Company C'k'w SCiex�C` 1 <br />Print Name iuA�i S,�Vq Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: %� �Y� �'G/ <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Date Issued -77-2- G Area Obv 1 <br />_Date Final Inspection By <br />Date <br />ACCOUNTING ONLY: AID# <br />WC ✓ -WAIVER — <br />C-57 Letter of Authorization to sign p&rnit ✓ E—n—cm>achment <br />PE CODES <br />FEE INFO AMOUNT REMfTTED <br />CH CK # <br />RPCV.BY <br />DAJE <br />P ! SERVICE T # <br />INVOICE <br />50 <br />& <br />�L p <br />7-109►b - <br />C-57 ✓ <br />WC ✓ -WAIVER — <br />C-57 Letter of Authorization to sign p&rnit ✓ E—n—cm>achment <br />do 9/27/00 <br />£0 <br />39vd <br />b007d H1dI-� ££b£89VGOZ <br />I£:EI 0007 -/b0/7 -I <br />