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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 />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 Joaquip County Public Health Services, Environmental Health Division. <br />r <br />Ti4a r ivion 'Ha 4) (.1 PAasseeitt s 2 Assessor's 15c1 \c, <br />WELL Location /i —) t Lig T - i-1 4440 (-\ hfli9Qross Street <Atrial- .4,e. . City L 0,01 <br />zip rc <br />L. 40 cJ DJ , EL DerAOL QJ <br />PROPERTY Owner TrAc 7 5+ r t- City S -TD 1"N ZIP9 5 2-0 2--Phone# r-LA 93 2 / Address 713 /,-,• <br />/144r 74c, 9 <br />C-57 Contractor L, v ikiLL it)) Address 9.5:3 /la D City Zip <br />y5-v-2. ' • Lic# -411111'6fF.'" Phone# 9 z -9 /3 -5-543o <br />Consultant/Sub Contractor A , Address I/005 1 1,v1.1)w-\ City -57.1x.j: ?)./-Lic# 6C5-7:1- Phone# 2cAcl 7 car_) <br />GIS Coordinates: X Y , Township <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />vv.") <br />Section Range <br />WORK TO BE PERFORD: <br />.NEW WELL / BORIN (CPT, EOPROBE, HYDROPUNCH,HAND-A4,GER, OTHER") <br />IL BORING # P c r-r r- <br />a ELL # <br />*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />fi PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION U AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br /> <br />AIR SPARGE 7gSH POINT <br /> <br />'--XSOIL BORING a HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Q\-; nt...t4 MULTIPLE CASINGS? fl YES 0 NO WELL CASING DIA: <br />CASING THICKNESS N/A- TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br />DEPTH OF GROUT SEALT,4L. Dairt TREMIE TYPE TO BE USED: :,AUGERS 0 HOSE <br />GROUT SEAL PUMPED: Q Yes fi No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 1),,r 1kr1( n <br />APPROX. BORING DEPTH 5o 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 14 /A- ( if YES, list specifications here): <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 />PR Signed x Title/Company G&J o5 L• c-c -r /5.) <br />p <br />- <br />Print NamejMi / Date Di 5 - ) C kirc 14Q <br />DEPARTMENT USE ONLY .1- <br />SITE MAP IN UNIT IV FILE, ADDRESS: /0 4-/y9 h:9.0Z-C <br />WORK PLAN DATED: 2e *6 2_ce,c3 7yzei,•-1 P " <br />Application Accepted By Date Issued Area <br />Grout Inspection Inspection By Date Final Inspection By Date Y-1 -02-- - <br />Destruction Inspection By V Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO <br />36o i <br />C-57 WC v -WAIVER <br />'g'et <br />T / SERVICE REQ 'ft INVOICE <br />aaf /-5-: I ;5003 <br />C-57 Letter of Authorization to sign perm. "Pncroachme 9/27/00 <br />AMOUNT REMITTED _CHECK # <br />M7-0 <br />REC'D BY DATE