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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 />1�;nl 11 R L <br />MITIGATION <br />UNIT IV <br />8 <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 />Assessors /�� <br />WELL Location �� S C, r) 'i f y �v% �IvcQ Cross Streetyt-,XAkly(N —City 5Auc t+c n Zip ,5- � y Parcel# <br />PROPERTY Owner�i0Ylr1 �C`1"Y�eC AddresslIjII-sl Coj,�, (I�5 �1,c C11ity S4inzZ Zip Lic#� <br />ocktcnZip ��5)G`(Phone# y��-�%1S <br />r�i��� lcl S�yt)/Phone# ��5-.3t-3 `&)t: <br />C-57 Contractor�1 4-1\�l!11y Address�s�, Ci MTtY <br />Consultant /Sub ConVactor/k�u •ncvM L �c����•rc:.M�.+b4Address g3� 5hc� \Z r_ CityS�a>tvn Lic# 6kOJ2%Phone# L/& 7"� <br />GIS Coordinates: X Y Township Range Section <br />I' <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HA D -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />gSOIL BORING # NS - P 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />FEE INFO <br />'Other: Grout Specifications: <br />CHECK # <br />COMMENTS: <br />DATE <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />�J <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 3 IN MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />0 EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL B PVC B OTHER: <br />— <br />C, <br />0 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL TS (! S TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br />AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 4Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />B <br />J'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: w^ 1C ^'� <br />6 <br />B OTHER:OTHER APPROX. BORING DEPTH FT 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_O <br />CONDUCTOR C, USING PROPOSED? (if YES, list specifications here): <br />Ye�hncloc <br />C?—c. <br />'COMMENTS: C � n c � � ' UGw�C['dC L7 �� � � 7 � n : <br />�e <br />r> <br />BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />�� <br />NOTE: OFFSITE <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />, <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordin races, Rules and Regulations, and all applicable California State Laws. <br />Signed x \ Title/Company ` Puilcowle �O SPcC�DI,St/%�IX uu.,c�a C 'o <br />Print Name `� S+ { yr i e ✓ Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: l0 <br />WORK PLAN DATED: I AN <br />Application Accepted By <br />Grout Inspection <br />Destruction Inspection <br />COMMENTS/COh <br />Date <br />ZZ/O <br />Date Issued 6-128-61 Area <br />Final Inspection By E=7to <br />.v <br />I' <br />ACCOUNTING ONLY:v AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERM R9T"4A- , <br />INVOICE <br />-56 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachme doc_ 9/27/00 <br />