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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 Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />Cross Street i7 )0.5-9--1'1.4.4. City A J74-4-‘\. Zip 25.33 Parcel# -11 <br />Phone# 7.-c/ <br />Phone# 92-5 <br />Phone# 2/ <br />GIS Coordinates: X <br /> <br />, Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED. <br />ERIEW WELL / BORING PI) GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') G DESTRUCTION (choose type below) <br />-El SOIL BORING # c--PT - 2,3/4Y 0 OVER-BORE <br />[I WELL # a PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />SITE <br />MITIGATION <br />UNIT IV <br />WELL Location J717J7 4;recct <br />.3'; I 6.3.4 <br />G-r-4 5,. Pr (l -5 <br />Consultant/Sub Contractor Agc.41. Address 2.e) 6-7 0.-4"de City Lic# <br />PROPERTY Owner <br />C-57 Contractor <br />Address / 7717 4-1re-/-1— i-Jv City Zip <br />Address 95 - ee) City/9,-,--/:•,--a. Zip ,Y3511 Lic# <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING HOLLOW STEM <br />a EXTRACTION AIR HAMMER/DRIVEN <br />El VAPOR MUD ROTARY <br />a AIR SPARGE VPUSH POINT <br />W.-SOIL BORING g HAND AUGER <br />[I OTHER: a OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE '-'MULTIPLE CASINGS? fl YES g NO WELL CASING DIA: A)g. <br />CASING THICKNESS 4/9 TYPE OF CASING: a STEEL I] PVC U OTHER: . <br />DEPTH OF GROUT SEAL ---/-f.t1 TREMIE TYPE TO BE USED: ff-AUGERS fl HOSE <br />GROUT SEAL PUMPED: Vies g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH / — BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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, Rul and Regu .tions, and all applicable California State Laws. <br /> Title/Company epren1,0,2_,- .0770":„egy•-• <br />Print Name f—Are ranGf-- Date 3 I irm /0/ <br />DEPARTMENT USE ONLY <br />Signed x <br />I 0.S(9 /1.".„( SITE MAP IN UNIT IV FILE, ADDRESS: (20—) <br />WORK PLAN DATED: Ic)--1L-A <br />Application Accepted By <br /> <br />Date <br />Date <br />• <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued OS) i <br />Final Inspection By <br />Area <br />Date <br />ACCOUNTING ONLY: AID# - FAC# • <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # — <br />INVOICE <br />36.5 1 L t71-- <br />c,..--d.--(1 -i'l (—) ..‘ (OA 11 113 —1 : : 0 - . • I es i -1 '7 //VI <br />C-57 <br /> <br />WC WAIVER <br /> C-57 Letter of Authorization to sign per ncroac men oc