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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•REF_UNDABLE 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 r lade in compliance with Sac <br />sloaquin County Development Title, Chapter S-1116.3 and the Standards of San Joaquin County Public Health Services, Enviror rental Health Division. <br />Assessor's <br />WELL Location 10 1. G. WiLSOla (A.M5 Cross Street ,2(&/ c111kkL Zip P-arcel# <br />PROPERTY Owner ebe.k. Address S1 C3 city Zp Phone#464- g'14 4-1 <br />C-57 Contractor Spe.cAfvvvi. Address 234 \id t510Jar,A. City5-Atru.. Lp s2os c#9220 Pnone# 46C-S II ?- <br />Consultant / Sub Contractor 6ravmd Zero Address iltut MLA St Cit&Citnn.. Li: # Phone# ZO4 Umetv <br />Secttr <br />WORK TO BE PERFORMED! <br />\KEW WELL SORINC (CF, GECPROBE, HYE.)ROPLINCH, HAND-AUGER, OTHER-) <br />SOIL BORING # <br />XWELL MIA/ IL\ <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />>i<ON1TORING ,XIOLLCW STEM <br />O EXTRACTION in AIR HAMMER'DRIVEN <br />VAPOR tIMUD ROTARY <br />0 AIR SPARGE fl PUSH POINT <br />fl SOIL BORING HAND AUGER <br />POTHER: p, OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE R.' MULTIPLE CAS NGS7 0 YES 2.1-0 WELL CASING DIA: e. <br />CASING THICKNESSSat4O TYPE OF CASING a STEEL VomC OTHER: <br />DEPTH OF GROUT SEAL 24 / TREMIE TYE TO BE USED: ;L-AUGERS ViOSE <br />GROUT SEAL PUMPED: AtYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: merA4 erw,ui 3 rtiitef- <br />APPROX. BORING DEPTH Sc BOLTED TRAFFIC BOX or 0 STOVE PPE <br />CONDUCTOR CASING PROPOSED? ( f YES, list specifications here). <br />*COMMENTS: <br /> <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 />SITE <br />MITIGATION <br />UNIT IV <br />GIS Coorcinates: X , Y ,Township Range <br />DESTRUCTION (choose type below) <br />CVER-BORE <br />0 PRESSURE GROUT <br />Grout Specifications: ,11.Ald- e124$4,4-3fem,-/- <br />I hereby certify that I have <br />County Ordillances <br />Signed x <br />Print Name 5,321. gar U <br />SITE MAP IN UNIT IV FILE, ADDTS: <br />WORK PLAN DATED: 60 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />pared this application and that the work will be done in accordance with San Joaquin <br />d Regulations, and all applicable California State Laws. <br />‘e5t) 415 <br /> Date Feb <br />DEPARTMENT USE ONLY <br />1,6)— WI [Ctie\UitL 3H- <br /> Area <br />Date Final Inspecdon By • t'se-,2011-1-b Date <br />Date <br /> Tit:e/Company <br />Date Issued <br />Da411 Zere) <br />2C01 <br />COMMENTS! CONDITIONS: <br /> <br />3 0 .t;S <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />..• <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE • -.- IT / SERVICE REQUEST IV ICE <br />:f7., 5 c ( -2 `7 <br />,i, -) I •--; 7.-,2-1tslo = ,.,4_,..5-.)----1 _ <br />9/27/03 WC -WAIVER C-57 Letter of Authorization to sign pe-mit Encroachment doc C-57