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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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 />Assessor's <br />WELL Location 2103 CAA^,^ -Ry aiie BL✓v• Cross Street Fi24NKLIN AV City S7c cKT0,V Zipq 4 Parcel# <br />PROPERTY Owner Sot -1n1 C P-PnGa Address & 6cA (-,91-2- 5 city ST0c1-TcW Zip9526P9 Phone# <br />/1 Nc.-H-o <br />C-57Contractor CA&ADE &e/LUNG Address b�32OrvMEC. GtPL�ECity L-Z(b�A Zip q5t2Lic# Phone# <br />J LAA <br />Consultant/ Sub Contractor .SC6&4 L,�TE(-d 4flO tj NAdd res s 361-q K I L6646 4AO city CA2fbvA Lic# Phone#(j/IC) 8(pI -bob <br />bkITE 100 <br />GIS Coordinates: X 'Y Township Range erection --~ _ <br />WORK TO BE PERFORMED: c\\ <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) DESTRUCTION (choose type below) <br />0 SOIL BORING # ,OVER -BORE <br />0 WELL # 0 -PRESSURE GROUT j <br />*Other: <br />COMMENTS: <br />Grout <br />PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,i <br />Q <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE •L5 MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />_v <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC ll OTHER: <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 36�57Q TREMIE TYPE TO BE USED: OA�UGERS 0 HOSE <br />AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes a NMAXIM UK FREE -;FALL O�J.L EPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:/'/01= <br />OTHER: P�62c, n ETER. a OTHER APPROX. BORING DEPTH 0 LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 Ordipances, 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: .1/' Z <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Title/Companyf� En1G/n1k7A-,2/, 5ECcF2 InJTE2nJ(-)nJItL <br />i <br />b 3 Cur.,, C� <br />Date <br />Inspection <br />J <br />-451 D <br />qj <br />d <br />W <br />v <br />1~ <br />7- <br />4, 4, <br />S�- <br />ffAVo� <br />ACCOUNTING ONLY: AID# cera - <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE MIT / SERVICE REQU INVOICE <br />p 2. <br />WD r-- <br />5?5 3 i 2-- � <br />l3 # <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Enc- mdvawtdac-- 9/27/00 <br />