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'. WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />21 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />7� (209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />'P' 0A ",,h T _ <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Er"V, =yf= <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application isdC ri` pj ith San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Heal' f?ion. <br />tt Assessor's <br />WELL Location .1103 (a�,.�ru 0A C �\vcA Cross Street frU'0%%\Aja City Zip i Parcel# 111- 1�-O;�i� <br />PROPERTY Ownef"� Address S Cityo "'— _Zip.. PhoneZ ^ LZS <br />C-57 Contractor Ci,Scc4c �' `\�nq Address 302 0111\tL C%fc\1 City RNL,,c),c�ic. Zip Lic# Phone# '116 63's iib9 <br />Consultant/ Sub Contractor— <br />5E Address 301- 9A City_' �.�,-d,;.�;,, _Lic# Phone# `iib 96i cycc <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER OTHER`) 1 B DESTRUCTION (choose type below) <br />a SOIL BORING # �, �, fl'OVER-BORE <br />0 WELL # 1 0 PRESSURE GROUT <br />'Other: Grout Specifications 1)0^ 6jtn%(\q bt4.. irvle '�w\ <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />e OLLOW STEM <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:—O <br />OTHER <br />&xV <br />6 <br />CONSTRUCTION SPECIFICATIONS l <br />DIA. OF BOREHOLE_I MULTIPLE CASINGS? DYES �O WELL CASING DIA:_6. �� <br />CASING THICKNESS0\ 40 TYPE OF CASING 0 STEEL If' VC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: (b:,\ harden ny �j2r���.�c mc.�erlr <br />APPROX. BORING DEPTH_ O', 501660 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_(if YES, list specifications here): <br />�t 1 st-c--Vt k " L -, <br />-z 1 <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 abd Regulations, and all applicable California State Laws. ' n <br />Title/J� JC�2nh� /�c�P_ t1 �nuu <br />Signed Cmm�anv <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: �,"' 2� <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / CONDITIONS: <br />Date - 0"gZ-— <br />o <br />ACCOUNTING ONLY: AID# Gnf <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT/ SERVIC T # INVOICE <br />C-57 WC / -WAIVER C-57 Letter of Authorization to sign permit ✓"' Erlcroac ime-ri­f-cT6c-4�' 9/27/00 <br />6 <br />