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L <br />WELL PERMIT APPLICATION FORM SITE <br />&ftK&jrSSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGAUNIT VTION <br />SENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />1 N ��v�'SioN s • 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />J�l�s 1 NCt - (209) 468-3449 OFF <br />Gl NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CO vA)7—t <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 r'14b Cross Street City -lrkh Zip Parcel# <br />PROPERTY Owner � AddressjZ&—c lk"I'l, r_ _CiZip f1G> Phone#J.e% '" <br />C-57 Contractor wI;ak1.r1c/ Address r' 0- 336 City rrJ G, 3* Zip�—�ic# 7/6* 7gPhone# /Y'7 37`+' `7' ' <br />Consultant /Sub Contractor Address _ />�as�e >� City lk?7 is# -S i Phone# 3�✓ �6�5�✓� <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />I] NEW WELL / BORING ( CPT <br />*Other: <br />(`OMMFNTS- <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />[]WELL# 44-y7 .?9`41,74 Y�lcycC' rii?1Cer• <br />Grout Specifica <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />[] PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[j MONITORING [j HOLLOW STEM DIA. OF BOREHOLE ihcMULTIPLE CASINGS? [] YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Si:A'JG' TYPE OF CASING: 0 STEEL 8 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �4 Nb' = / TREMIE TYPE TO BE USED: a -AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: VYes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />!° <br />0 OTHER: ir =- <br />0 OTHER APPROX. BORING DEPTH lA I BOLTED 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 />I 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 x�/ Title/Company 41' <br />Print Name t ' ,f'c'� c' �' �t'y/riPrJ.Q Date 2c� j <br />,p DEPARTMENT USE <br />E ONLY <br />SITE MAP IN UNIT IV FILE, ADD SS: <br />WORK PLAN DATED: /Z oa <br />Application Accepted By. / <br />Date Issued /b —0 1 Area Q� d T <br />Grout Inspection By Date Final Inspection By <br />Destruction <br />Date <br />COMMENTS /CONDITIONs* Nom` bo—D17 77 To t MI <br />ACCOUNTING ONLY:AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ERMIT / SERVICE R EST # <br />INVOICE <br />�D 2580 <br />- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encronc me oc 91e7100 <br />